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Presented  by 
Mrs.  Frank  C.  Peirsol 


COLLEGE  OF  OSTEOPATHIC  PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


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J)ISEASES 


OF  THE 


Stomach,  Intestines, 


AND 

^"7 


Pancreas 


BY 

ROBERT    COLEMAN    KEMP,    M.  D. 

Professor  of   Gastro-intestinal    Diseases  at  the   Fordham  University  Medical  School; 
Gastro-enterologist  at  the  Fordham  University  Clinic;    Consulting  Physician  and 
Gastro-enterologist   to  the  Manhattan  State  Hospital;  Late  Junior  Physician 
to  the  Roosevelt   Hospital;    Late  Gastro-enterologist  to  the  New  York 
Red  Cross  Hospital,  St.  Bartholomew's  Clinic,  and  West  Side  Ger- 
man    Dispensary;     Member     American     Medical     Association; 
Fellow    New  York  Academy  of  Medicine;    Member  Amer- 
ican   Therapeutic    Society,   Medical  Association  of  the 
Greater  City  of  New  York,  etc. 


THIRD  EDITION,   REVISED.    WITH  438   ILLUSTRATIONS 


PHILADELPHIA  AND    LONDON 

W.    B.    SAUNDERS    COMPANY 

1917 


VAiX  ^  V  60 


A 


Copyright,  1910,  by  W.  B.  Saunders  Company.    Reprinted  July,  igio,  September,  1910,  and  June, 

1911.     Revised,  reset,  reprinted,  and  recopyrighted  August,  1912.     Reprinted  March, 

1913.    Revised,  reset,  reprinted,  and  recopyrighted  February,  1917. 

Copyright,  1917,  by  W.  B.  Saunders  Company 


^niNTeO     IN     AMERICA 

PRESS      OF 

W       B.     SAUNDERS      COMPANY 

PMIL.ADEk.PMIA 


TO 

MtUtam  ^,  SlinmBon,  M.  i.,  IC2j.S., 

CONSULTING  PHYSICIAN  TO  THE  ROOSEVELT  AND  RED 
CROSS  HOSPITALS  AND  LATE  PRESIDENT 
OF  THE  NEW  YORK  ACADEMY 

OF    MEDICINE, 
THIS   VOLUME    IS   INSCRIBED 
AS   A    TRIBUTE  TO  HIS   HIGH   PROFESSIONAL    ATTAIN- 
MENTS   AND    IN    REMEMBRANCE   OF   HIS 
MANY    ACTS    OF    KINDNESS, 
BY  THE  AUTHOR 


PREFACE  TO  THE  THIRD  EDITION 


In  view  of  the  great  value  of  the  ic-rays  as  an  aid  to  diagnosis  in  the 
gastro-intestinal  tract,  a  special  section  has  been  devoted  in  this  new  edi- 
tion to  the  radiography  of  gastric  ulcer,  gastric  cancer,  duodenal  ulcer 
and  gall-bladder  disease  and  in  addition  there  are  a  large  number  of  radio- 
graphs of  other  conditions.  IVIany  of  these  are  from  cases  of  the  author, 
for  whom  some  excellent  radiography  has  been  performed  by  Dr.  Sinclair 
Tousey.  I  feel  that  I  must  express  my  indebtedness  to  Dr.  Lewis  Gregory 
Cole  for  his  description  of  the  motility  of  the  normal  stomach  and  of  the 
duodenal  cap.  There  is  a  chapter  on  Lane's  kinks,  Jackson's  membrane, 
duodenal  dilatation  and  ileo-cecal  valve  incompetency.  Although  Lane's 
investigations  are  of  great  value,  and  in  some  cases,  release  of  these  kinks 
by  severance,  or  separation  of  the  adhesions,  may  be  of  benefit,  the  writer 
at  the  present  time  is  conservative  and  hardly  feels  the  radical  operation 
of  resection  of  the  large  intestine  as  advocated  by  Lane  to  be  a  justifiable 
procedure  except  under  rare  conditions.  The  Mayos,  with  their  large 
surgical  experience,  report  only  twenty  cases  of  resection  of  the  cecum, 
ascending  and  part  of  the  transverse  colon,  apparently  for  stasis  of  such 
severe  type  that  there  was  nearly  obstipation,  in  which  adhesions  were 
a  marked  factor. 

In  view  of  the  promiscuous  and  improper  use  of  the  term  auto-intoxi- 
cation, I  have  inserted  a  brief  section  on  " Subinf ection"  and  "Protein 
Absorption,"  and  have  enlarged  my  work  on  chronic  intestinal  putre- 
faction. Herter  held  that  the  Bacillus  aerogenes  capsulatus,  by  produc- 
ing excessive  intestinal  putrefaction,  was  a  factor  in  the  production  of 
pernicious  anemia.  Streptococci  (of  oral  origin  sometimes)  are  found  in 
connection  with  the  above  in  some  cases,  and  experimentally  a  severe 
grade  of  anemia  with  spinal  degeneration  in  the  columns  of  GoU  has  been 
produced  in  dogs,  by  repeated  injections  of  colon  bacilli  of  low  virulence. 
Therefore  intestinal  putrefaction,  or  the  same  plus  infection  (streptococci) 
from  the  mouth,  or  subinfection  may  all  produce  pernicious,  or  a  severe 
type  of  anemia.  Incidentally  acute  articular  inflammation,  resembling 
rheumatism,  may  be  found  with  colon  bacillus  infection  (colon  bacillus  in 
the  urine).  These  facts  all  illustrate  that  infection  may  arise  from 
without  or  may  have  its  origin  from  almost  any  part  of  the  gastro-intes- 
tinal tract,  from  the  mouth  to  the  anus. 

Since  many  physicians  have  neither  the  time  nor  the  opportunity  to 
devote  to  a  clinical  course  in  gastro-enterology,  and  next  in  value  for  the 
purpose  of  instruction,  is  the  employment  of  photography,  I  have  taken 
extensive  advantage  of  the  latter  method.  Many  of  the  illustrations  are 
from  photographs  of  patients  at  the  Manhattan  State  Hospital  taken  by 
Mr.  Hill,  the  official  photographer,  for  whose  services  I  am  indebted  to 
Dr.  Wm.  Mabon,  the  medical  director.  Some  of  the  illustrations  have 
been  made  by  my  artist,  Mr.  Thomas  Nast,  Jr.,  from  models. 

5 


6  PREFACE 

As  visceral  displacements  have  assumed  an  important  position,  their 
symptoms,  diagnosis  and  treatment,  notably  by  mechanical  methods,  are 
particularly  described. 

The  writer  is  indebted  to  Dr.  E.  E.  Smith  for  a  brief  but  practical  de- 
scription of  the  tests  of  the  intestinal  functions. 

It  has  been  my  endeavor  to  clearly  set  forth  the  indications  for  surgical 
procedure  and  to  demonstrate  the  futility  of  medical  treatment  in  surgical 
conditions  such  as  in  benign  stenosis  of  the  pylorus,  and  the  necessity  of 
early  exploration  for  the  purpose  of  diagnosis  in  suspected  carcinoma  of 
the  stomach.  The  rc-rays  will  aid  in  determination  of  a  surgical  condition, 
but  often  in  the  early  stages  will  not  determine  whether  it  is  benign  or 
malignant. 

The  writer  holds  that  chronic  gastric  ulcer  should  be  considered  as  a 
precancerous  condition  and  be  treated  by  radical  procedure  (resection). 

Typhoid  fever  is  again  included  in  this  volume,  on  account  of  its  in- 
testinal complications  and  for  the  purpose  of  differential  diagnosis.  In 
the  chapter  on  this  subject,  the  writer  particularly  discusses  the  question 
of  diet  and  in  his  belief  the  excessively  high  calorie  values  which  have  been 
advocated.     There  is  a  special  chapter  devoted  to  "Diverticulitis." 

Pure  gastro-intestinal  neuroses  I  believe  to  be  extremely  rare.  Some 
of  these  conditions  are  explainable  as  due  to  disturbance  of  the  vegetative 
nervous  system,  vagotonia  and  sympathetico-tonia,  to  which  I  have  given 
considerable  space;  particular  attention  is  moreover  directed  to  reflex 
gastro-intestinal  disturbances  emanating  from  disease  of  the  gall-bladder, 
appendix  and  other  organs.  There  are  other  important  additions  to  this 
volume — notably  on  hypochlorhydria  and  on  the  treatment  of  obesity. 

Robert  Coleman  Kemp. 
New  York  City, 
February,  1917. 


PREFACE 


In  view  of  the  excellent  works  on  diseases  of  the  stomach  and 
intestines  that  have  been  placed  before  the  medical  profession,  the 
publication  of  a  new  book  on  these  subjects  might  almost  seem  to 
be  superfluous.  From  a  great  accumulation  of  material,  it  is  often 
difficult  for  the  general  practitioner  to  select  simple  and  practical 
methods,  and  it  is  the  endeavor  that  this  volume  should  render 
service  in  this  special  direction. 

Many  physicians  have  neither  time  nor  opportunity  to  devote 
to  a  practical  clinical  course,  and  next  in  value  to  this  for  the  pur- 
pose of  instruction  is  the  employment  of  photography  to  demon- 
strate the  methods  of  diagnosis  and  treatment.  Of  this  I  have 
endeavored  to  take  advantage.  Many  of  the  illustrations  are  from 
photographs  of  patients  at  the  Manhattan  State  Hospital,  taken  by 
Mr.  Hill,  the  official  photographer,  for  whose  services  I  am  indebted 
to  the  courtesy  of  Dr.  Wm.  Mabon,  the  Medical  Superintendent. 
Some  of  the  illustrations  have  been  made  by  my  artist  from 
models. 

As  visceral  displacements  have  recently  assumed  an  important 
position,  their  symptoms,  diagnosis,  and  treatment,  notably  by  me- 
chanical methods,  are  specially  described.  Typhoid  fever  is  included 
in  this  volume  on  account  of  its  intestinal  complications  and  for  the 
purpose  of  differential  diagnosis. 

A  chapter  is  devoted  to  Diverticulitis,  which  has  become  an 
important  subject. 

The  endeavor  has  been  made  to  indicate  as  clearly  as  possible 
the  conditions  which  call  for  surgical  procedure. 

ROBERT   COLEMAN   KEMP. 
New  York  City. 


CONTENTS 
Part  I 

CHAPTER   I 

PAGE 

Anatomy  of  the  Stomach  and  Intestines 17 

Anatomy  of  the  Stomach 17 

Anatomy  of  the  Intestines 22 

Histology  of  the  Large  Intestine 32 

CHAPTER  II 

Physiology  of  Digestion 33 

.    The  Gastric  Juice 33 

Intestinal  Digestion 38 

,  CHAPTER  III 

Interrogation  of  the  Patient  (History) 46 

CHAPTER  IV 

General  Methods  of  Physical  Examination 49 

General  Inspection 49 

Topographic  Anatomy 74 

Physical  Examination  of  the  Liver  and  Gall-bladder 75 


Part  II 

DISEASES  OF  THE  STOMACH 

CHAPTER  V 

Methods  of  Physical  Examination  of  the  Stomach 89 

Rontgen  Rays  (x-Rays)  in  the  Diagnosis  of  Diseases  of  the  Esoph- 
agus and  Stomach 113 

Radium  Transillumination  of  the  Stomach 134 

Radium  Photographs  of  the  Stomach 135 

Conclusions 135 

CHAPTER  VI 

Examination  of  the  Functions  of  the  Stomach 136 

Test  Meals 136 

Method  of  Aspiration  of  the  Gastric  Contents 139 

Examination  of  the  Ingesta 143 

Abnormal  Constituents  of  the  Stomach  Contents 158 

Microscopic  Examination  of  the  Gastric  Contents 163 

Determination  of  the  Absorptive  Function  of  the  Stomach 1 68 

9 


lO  CONTENTS 

CHAPTER  VII 

Diet 172 

Diet  in  Health 172 

Diet  in  Disease 192 

CHAPTER  VIII 

Local  Treatment  of  the  Stomach 196 

Lavage 196 

Stomach  Powder-blower 214 

Electricity 2l6 

CHAPTER  IX 
Massage,   Vibratory    Massage,    Hydrotherapy,    Counterirritatign, 

Orthopedic  Appliances 221 

Massage 221 

Vibratory  Massage * 221 

Local  Hydrotherapy ' 224 

Counterirritation 225 

Orthopedic  Methods 225 

CHAPTER  X 

Catarrh  of  the  Stomach 236 

Acute  and  Chronic  Gastritis 236 

Acute  Gastritis 236 

Simple  Acute  Gastritis 236 

Toxic  Gastritis 243 

Phlegmonous  Gastritis 246 

Chronic  Gastritis 248 

Acid  Gastritis 248 

CHAPTER  XI 

AcHYLIA  GaSTRICA,    AcHLORHYDRIA   HiEMORRHAGICA   GaSTRICA 262 

Achylia  Gastrica 262 

Achlorhydria  Haemorrhagica  Gastrica 269 

CHAPTER  XII 
Hematemesis,  Ulcer  of  the  Stomach,  Exulceratio  Simplex,  Acute 

AND  Chronic  Erosions,  Perigastritis,  Perigastric  Adhesions.  .  276 

Gastric  Hemorrhage 276 

Ulcer  of  the  Stomach 277 

Exulceratio   Simplex    (Dieulafoy)   or   Superficial   Ulceration   of   the 

Stomach , 314 

Gastric  Erosions 315 

Acute  Erosions  (Hemorrhagic  Erosions) 315 

Chronic  Erosions , 315 

Perigastritis  and  Perigastric   Adhesions 318 

CHAPTER  XIII 

Cancer  of  the  Stomach  (Carcinoma  Ventriculi),  Other  Tumors  of 
THE   Stomach,  Apparent  Tumors  of  the  Stomach,   Foreign 

Bodies  in  the  Stomach 320 

Cancer  of  the  Stomach  (Carcinoma  Ventriculi) 320 

Other  Tumors  of  the  Stomach 363 

Apparent  Tumors  of  the  Stomach » 366 

Foreign  Bodies  in  the  Stomach 367 


CONTENTS  1 1 

CHAPTER  XIV 

Functional  Diseases  of  the  Stomach 370 

Hyperacidity  (Hyperchlorhydria) 370 

Hypochlorhydria  and  Achlorhydria 383 

Gastrosuccorrhea  (Continuous  Secretion  of  Gastric  Juice) 386 

Gastrosuccorrhea  (Continua  Periodica) 387 

Gastrosuccorrhea  (Continua  Chronica) 391 

Alimentary  Hypersecretion 396 

CHAPTER  XV 

Disturbances  of  the  Motor  Function  of  the  Stomach,  Acute  Atony, 
Chronic  Atony,  Acute  Dilatation  of  the  Stomach,  Chronic 

Dilatation  of  the  Stomach 398 

Atony  of  the  Stomach — Diminished  Peristole 398 

Acute  Atony  of  the  Stomach — Acute  Diminished  Peristole 398 

Chronic  Atony  of  the  Stomach — Chronic  Diminished  Peristole. .  399 
Acute  Dilatation  of  the  Stomach — Acute  Diminished  Peristole  with 

Dilatation 401 

Chronic  Dilatation  of  the  Stomach — Diminished  Peristole  with  Chronic 

Dilatation 414 

Atonic  Dilatation  of  the  Stomach — EHminished  Peristole  with  Gas- 
tric Dilatation 416 

Obstructive  Type  (Stenotic)  of  Ectasia 419 

Diagnosis .' 422 

Treatment 425 

Treatment  of  Stenotic  Dilatation  (Benign  Stenosis) 431 

Treatment  of  Malignant  Stenosis 433 

Complications  of  Chronic  Ectasy 433 

Gastric  Tetany 433 

Convulsions,  Epilepsy 435 

CHAPTER  XVI 

Anomalies  in  the  Position  and  Form  of  the  Stomach,  Hour-glass 

Stomach,  Dislocations,  Gastroptosis 437 

Hour-glass  Stomach 437 

Dislocation  of  the  Stomach 439 

Diaphragmatic  Hernia,  Eventration  of  the  Diaphragm — Volvulus  of 

Stomach 439 

Gastroptosis,  Enteroptosis,  G16nard's  Disease 442 

CHAPTER  XVII 

Nervous  Affections  of  the  Stomach 469 

Sensory  Neuroses  of  the  Stomach 470 

Bulimia .' 470 

Parorexia  (Perversion  of  Appetite) 472 

Polyphagia 472 

Akoria 472 

Nervous  Anorexia  (Anorexia  Nervosa) 472 

Sensations  Within  the  Stomach 473 

Abnormal  Sensations 474 

Hyperesthesia  of  the  Stomach '. 474 


12  CONTENTS 

Nervous  Affections  of  the  Stomach:  Sensory  Neuroses  of  Stomach — 

Gastralgia 475 

Gastralgokenosis  (Boas) 479 

Motor  Neuroses  of  the  Stomach 479 

Hypermotility  of  the  Stomach 479 

Peristaltic  Restlessness  of  the  Stomach  (Kussmaul) 480 

Antiperistaltic  Restlessness  of  the  Stomach 481 

Incontinence  of  the  Pylorus 481 

Spasm  of  the  Pylorus  (Pylorospasmus) 482 

Atony  of  the  Stomach 485 

Hypanakinesis  Ventriciili  (Einhorn) 485 

Hyperanakinesis  Ventriculi  (Einhorn) 485 

Spasm  of  the  Cardia  (Cardiospasmus) 485 

Insufficiency  of  the  Cardia 487 

Singultus  Gastricus  Nervosus 488 

Pyrosis  (Heart-bum) 489 

Regurgitation 489 

Rumination 490 

Nervous  Vomiting  (Vomitus  Nervosa) 490 

Periodic  Vomiting  (Von  Leyden) 491 

Cyclic  Vomiting  in  Children 492 

Juvenile  Vomiting 494 

Reflex  Vomiting 494 

Idiopathic  Nervous  Vomiting 494 

Pneumatosis 495 

Secretory  Neuroses 495 

Nervous  Dyspepsia  (Leube) 496 

CHAPTER  XVIII 

Dyspeptic  Asthma 499 

CHAPTER  XIX 

The  Stomach  Functions  in  Diseases  of  Other  Organs 501 

Functions  of  the  Stomach  in  Acute  Febrile  Diseases 501 

Chronic  Febrile  Conditions 502 

Condition  of  the  Stomach  in  Pulmonary  Tuberculosis 502 

Pellagra 503 

Chlorosis  and  Anemia 503 

Heart  Lesions 504 

Diseases  of  the  Liver 504 

Aneurysm 504 

Diseases  of  the  Kidneys 504 

Diabetes 505 

Arthritis  Deformans 505 

Gout 505 

Malaria 505 

Diseases  of  the  Eye .  . . 506 

Diseases  of  the  Skin 506 

Tuberculosis  of  the  Stomach 507 

Syphilis  of  the  Stomach 508 

Gastric  Ulcer  (Syphilitic) 509 

Syphilitic  Tumor  of  the  Stomach 509 

Syphilitic  Pyloric  Stenosis 509 

Syphilitic  Cirrhosis  of  the  Stomach 511 

Gastric  Crises  of  Tabes 512 


CONTENTS  13 

Part  III 

DISEASES  OF  THE  INTESTINES 

CHAPTER    XX 
Methods  of   Examination  of  the   Intestines;   Examination   of  the 

Feces;  Mechanical  Procedures 515 

Physical  Examination  of.  the  Intestines 516 

Inspection  of  the  Rectum — Proctoscopy  and  Sigmoidoscopy 517 

Transillumination  of  the  Intestines 528 

Inflation  of  the  Intestines  with  Carbonic  Acid  Gas  or  Air 529 

Lavage  of  the  Bowel  for  Diagnosis 532 

Examination  of  the  Feces 532 

Testing  the  Intestinal  Functions 543 

Mechanical  Procedures 552 

CHAPTER  XXI 
Diet,  Intestinal  Dyspepsia,  Chronic  Intestinal  Putrefaction  (Indolic 
Type),  Indicanuria,  Saccharobutyric  Putrefaction,  Subinfec- 
TiON,  Protein  Absorption,  Botulism,  Hydrogen  Sulphid  Auto- 
intoxication, Enterogenic  Cyanosis,  Meteorism,  Enteralgia, 
Visceral  Arteriosclerosis,  Senile  Dyspepsia,  Anomalies,  In- 
testinal Sand 568 

Diet 568 

Intestinal  Dyspepsia 570 

Subinfection,  Protein  Absorption,  and  Chronic  Intestinal  Putrefaction  571 

Indicanuria 574 

Saccharobutyric  Type  of  Intestinal  Putrefaction 578 

Acidosis  (Acetonuria) 580 

Botulism 582 

Hydrogen  Sulphid  Auto-intoxication 583 

Enterogenic  Cyanosis 583 

Meteorism;  Tympanites ? , 584 

Intestinal  Pain  (Intestinal  Colic,  Enteralgia) 587 

Visceral  Arteriosclerosis 588 

Senile  Dyspepsia 590 

Anomalies  in  the  Position  and  Form  of  the  intestines;  Enteroptosis .  592 

Intestinal  Sand 593 

CHAPTER  XXII 

Infections  by  the  Bacillus  Coli 594 

CHAPTER    XXIII 

Constipation"  and  Diarrhea 609 

Constipation 609 

Diarrhea 624 

Diarrhea  Due  to  Irritation  of  the  Bowel  Contents 625 

Diarrhea  Due  to  Irritants  Transmitted  in  the  Blood 626 

Diarrhea  Nervosa  (Nervous  Diarrhea) 626 

Diarrhea  from  Exposure  to  Cold  and  Wet 627 

Treatment  of  Diarrhea 627 

CHAPTER  XXIV 

Chronic  Intestinal  Stasis 630 

Chronic  Dilatation  of  the  Duodenum 634 

Movable  Cecum 639 

Incompetency  of  the  Ileocecal  Valve 640 


14  .     CONTENTS  , 

CHAPTER  XXV 
Intestinal    Catarrh,    Enteritis,     Colitis,     Catarrhal    Sigmoiditis, 

Proctitis,  Phlegmonous  Enteritis. 643 

Acute  and  Chronic  Intestinal  Catarrh 643 

Acute  Intestinal  Catarrh 643 

Chronic  Intestinal  Catarrh  (Chronic  Colitis) 652 

Proctitis 663 

Phlegmonous  (Purulent)  Enteritis 665 

CHAPTER  XXVI 

Dysentery 666 

Diphtheritic  Dysentery 666 

Predisposing  Causes  and  Climatic  Location 667 

Amebic  Dysentery 668 

Bacillary  Dysentery 692 

CHAPTER  XXVII 

Typhoid  Fever,  Paratyphoid  Fever,  Brill's  Disease 700 

Typhoid  Fever 700 

Paratyphoid  Fever 718 

Mild  Endemic  Typhus,  or  Brill's  disease '.  .  .  .  .  720 

CHAPTER  XXVIII 
Intestinal  Hemorrhage,  Intestinal  Ulcers,  Duodenal  Ulcer,  Diseases 

of  the  Blood-vessels  (Embolism  and  Thrombosis) 724 

Intestinal  Hemorrhage 724 

Ulcers  of  the  Intestines 724 

Duodenal  Ulcers 724 

Simple  Duodenal  Ulcer 725 

Intestinal  Ulcers  from  Cutaneous  Burns 754 

Embolic  and  Thrombotic  Ulcers 754 

Secondary  Tubercular  Ulcers  of  the  Intestines  (Tuberculosis) . .  .  757 

Catarrhal  and  Follicular  Ulcers 758 

Ulcerative  Colitis 758 

Stercoral  or  Decubital  Ulcers 758 

Ulcers  in  Acute  Infectious  Diseases 759 

Ulcers  in  Constitutional  Diseases 759 

Toxic  Ulcers .' i 759 

Syphilitic,  Gonorrheal,  and  Cancerous  Ulcers 759 

Intestinal  Myiasis .' 760 

General  Symptoms  of  Intestinal  Ulceration 760 

Treatment 762 

Diseases   of  the   Blood-vessels;   Embolism  and   Thrombosis  of  the 

Mesenteric  Arteries  and  Veins  (Infarction  of  the  Bowel) 763 

CHAPTER  XXIX 

Neoplasms  of  the  Intestines 767 

Malignant  Growths 767 

Carcinoma  of  the  Intestines 767 

Sarcoma  and  Lymphosarcoma  of  the  Intestines 778 

Benign  Tumors  of  the  Intestines 779 

Gas  Cysts  of  the  Intestines 781 

CHAPTER  XXX 
Hemorrhoids,  Prolapse  of  Rectum,  Fissure,  Abscess  of  the  Rectum, 

Pruritus  Ani,  Fistula  in  Ano '. 782 

Hemorrhoids 782 


CONTENTS  15 

Abscess  of  the  Rectum 797 

Pruritus  Ani 799 

Fistula  in  Ano 799 

CHAPTER  XXXI 

Appendicitis 801 

CHAPTER  XXXII 
Diverticulitis,  Peridiverticulitis,  Diseases  of  Meckel's  Diverticu- 
lum   839 

Meckel's  Diverticulum  and  Its  Diseases 856 

CHAPTER  XXXIII 

Intestinal  Obstruction,  Acute  and  Chronic 859 

Acute  Intestinal  Obstruction 859 

Chronic  Intestinal  Obstruction 883 

CHAPTER  XXXIV 
Vagotonia,   Sympatheticotonia,   Visceral   Crises    in   the    Erythema 

Group,  Umbilical  Dyspepsia 892 

Vagotonia    and     Sympatheticotonia. — Their    Relation     to     Gastro- 
intestinal Symptoms 892 

Visceral  Crises  in  the  Erythema  Group 896 

Umbilical  Dyspepsia 899 

CHAPTER  XXXV 

Nervous  Diseases  of  the  Intestines 900 

Motor  Neuroses  of  the  Intestines 900 

Sensory  Neuroses  of  thp  Intestines 903 

Secretory  Neuroses  of  the  Intestines 905 

Intestinal  Neurasthenia 905 

Mucous  Colic  (Membranous  Enteritis) 905 

CHAPTER  XXXVI 

Obesity 915 

CHAPTER  XXXVII 

Intestinal  Parasites 920 

Protozoa 920 

Amebae 920 

Sporozoa 920 

Intestinal  Psorospermiasis 920 

Infusoria 920 

Vermes 924 


Part  IV 

DISEASES  OF  THE  PANCREAS 

CHAPTER  XXXVIII 

The  Pancreas  and  Its  Anomalies — Surgical  Relations 955 

Anatomic  Anomalies  of  the  Pancreas 959 

Surgical  Relations 961 

CHAPTER  XXXIX 

Histology  of  the  Pancreas — Physiology 964 

Physiology  of  the  Pancreas 9^9 


1 6  CONTENTS 

CHAPTER    XL 

Methods  of  Diagnosis  in  Pancreatic  Disease 972 

Testing  the  Functions  of  the  Pancreas 972 

Examination  of  the  Duodenal  Contents 976 

The  Fats  in  the  Feces 980 

The  Use  of  Pancreatic  Enzymes  as  an  Aid  to  Diagnosis;  Pancreatic 

Infantilism 9§3 

Carbohydrates  in  the  Stool.     Pancreatic  Diastatic  Ferments 985 

General  Character  of  the  Stool 986 

Changes  in  the  Urine  in  Pancreatic  Disease 987 

The  Blood  in  Diseases  of  the  Pancreas 991 

CHAPTER   XLI 

General  Symptoms  and  Diagnosis  of  Pancreatic  Disease 993 

Physical  Signs 994 

Symptoms 996 

CHAPTER   XLII 
Injuries  of  the    Pancreas;    Classification  of  Acute  and  Chronic 

Inflammation  of  the  Pancreas;  Catarrh  of  the  Pancreas..  .  .  looi 

Injuries  of  the  Pancreas looi 

Classification  of  Acute  and  Chronic  Inflammation  of  the  Pancreas. . .  1002 

Ftmctional  Disturbances  of  the  Pancreas 1005 

Pancreatic  Achylia 1005 

Catarrh  of  the  Pancreas 1005 

CHAPTER  XLIII 

Acute  Pancreatitis;  Chronic  Pancreatitis 1008 

Acute  Pancreatitis 1008 

Acute  Hemorrhagic  Pancreatitis 1 008 

Gangrenous  Pancreatitis 1012 

Symptoms  of  Acute  Pancreatitis  (Hemorrhagic  and  Gangrenous)  1013 

Suppurative  Pancreatitis 1015 

Chronic  Pancreatitis 1018 

CHAPTER  XLIV 

Fat  Necrosis;  Tuberculosis;  Syphilis;  Pancreatic  Calculi 1029 

Fat  Necrosis 1029 

Tuberculosis 1 030 

Syphilis 1031 

Pancreatic  Calculi 1031 

CHAPTER  XLV 

Cysts  of  the  Pancreas;  Neoplasms 1035 

Cysts 1035 

Neoplasms I044 

Carcinoma : , 1044 

Sarcoma :  .  .  .  1 048 

Adenoma 1049 

CHAPTER     XLVI 
Degenerative  Changes  of  the  Pancreas;  The  Pancreas  and  Diabetes; 

Hemochromatosis 1050 

Degenerative  Changes  of  the  Pancreas 1050 

The  Pancreas  and  Diabetes 1051 

Hemochromatosis 1053 

Index 1055 


DISEASES 

OF  THE 

STOMACH,  INTESTINES,  AND  PANCREAS 


PART  I 

CHAPTER  I 

ANATOMY   OF   THE   STOMACH   AND   INTESTINES 
ANATOMY  OF  THE  STOMACH 

A  BRIEF  description  will  be  given  of  the  anatomy  of  the  stomach, 
but  for  a  complete  exposition  of  the  subject  the  reader  is  referred  to  any- 
standard  anatomy. 

The  stomach  lies  in  the  epigastric  and  left  hypochondriac  regions, 
about  five-sixths  of  it  to  the  left  of  the  median  line.  The  larger  end, 
the  fundus,  fits  into  the  concave  left  vault  of  the  diaphragm.  Modern 
investigation  by  means  'of  the  x-rays  has  demonstrated  that  the  stomach 
does  not  lie  transversely  across  the  abdomen,  as  was  formerly  described. 
The  fundus  is  nearly  vertical,  and  the  pyloric  portion  nearly  transverse — 
that  is,  of  course,  with  the  patient  in  the  standing  posture.  The  position 
may  be  described  as  J  shaped,  that  is,  a  reversed  L  (Fig.  i).  It  may  be 
well  compared  to  a  gourd. 

The  cardiac  orifice  (C),  the  junction  of  the  esophagus  and  stomach 
(the  esophageal  orifice),  is  fixed  and  lies  behind  or  a  little  to  the  left  of 
the  sternal  junction  of  the  left  seventh  cartilage  (seventh  rib),  or  about 
1)4  inches  from  the  edge  of  the  sternum,  in  the  left  parasternal  line,  on 
a  level  with  the  spinous  process  of  the  ninth  dorsal  vertebra.  The  cardia 
is  situated  4^2  inches  from  the  anterior  surface  of  the  abdomen.  The 
point  of  communication  with  the  small  intestine  is  called  the  pylorus 
(P),  and  shows  a  furrow  on  the  outer  surface  and  within  a  protruding  fold 
(the  valve  of  the  pylorus). 

The  pylorus  (P)  lies  between  the  right  sternal  and  parasternal  lines, 
slightly  below  the  tip  of  the  ensiform  process,  and  corresponds  to  the 
spinous  process  of  the  twelfth  dorsal  vertebra.  It  descends  slightly 
when  the  stomach  is  distended  and  moves  somewhat  to  the  right.  A  line 
(+),  drawn  in  the  axis  of  the  esophagus  through  the  stomach  to  its 
lower  border,  cuts  oflF  about  one-fourth  of  the  organ  to  the  left.  This 
portion  is  called  the  greater  cul-de-sac  or  fundus  (F). 

The  fundus  (F)  rises  as  high  as  the  lower  border  of  the  left  fifth  rib 
2  17 


i8 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


in  the  mammillary  line,  slightly  above  and  behind  the  apex  of  the  heart, 
and  from  i  to  2  inches  higher  than  the  cardia.  It  is  in  contact  with  the 
diaphragm  above,  and  to  the  left  with  the  spleen  and  left  kidney. 

The  lesser  curvature  (L)  lies  to  the  left  of  the  vertebral  column, 
passes  downward  and  parallel  with  it,  and  then  crosses  it  to  the  upper 
border  of  the  pylorus. 

The  greater  curvature  (G)  forms  the  fundus  and  lower  border  of  the 
stomach  and  extends  to  the  lower  border  of  the  pylorus.  The  lower 
border,  when  the  organ  is  distended,  lies  about  two  to  three  fingers' 
breadth  (1^-2  to  23^  inches'  above  the  umbilicus. 


Fig.   I. — The  stomach:  C,  Cardia;  F,  fundus;  P,  pylorus;  L,  lesser  curvature;  G,  greater 
curvature  (modified  from  W.  J.  Mayo). 

The  volume  of  the  stomach  varies  according  to  its  contents.  Dehio 
has  shown  that  the  healthy  stomach  when  empty  is  contracted  and 
hidden  away  in  the  left  cavity  of  the  diaphragm,  and  it  is  the  colon  that 
we  then  demonstrate  by  percussion. 

The  pancreas  and  splenic  vessels  lie  behind  the  stomach.  The  an- 
terior surface  is  overlapped  above  by  the  liver,  the  left  lung,  and  the 
seventh,  eighth,  and  ninth  ribs.  Below  it  is  in  relation  with  the  abdominal 
wall. 


ANATOMY    OF    THE    STOMACH   AND   INTESTINES 


19 


The  pyloric  end,  the  lesser  curvature,  and  the  cardia  lie  behind  and 
beneath  the  quadrate  and  left  lobes  of  the  liver. 

Traube's  space  is  the  area  in  which  the  stomach  lies  in  direct  contact 
with  the  ribs,  and  is  bounded  above  by  the  liver  and  left  lung,  externally 
by  the  spleen,  and  the  inner  border  is  formed  by  the  free  costal  margin. 
Both  here  and  in  the  epigastric  region  pure  gastric  tympany  can  be  elicited. 

When  the  stomach  is  distended,  the  lesser  curvature  is  directed  ob- 
liquely backward  toward  the  spine,  the  posterior  wall  looking  some- 
what downward  and  the  anterior  wall  slightly  upward.  The  transverse 
colon,  if  distended,  may  overlap  the  greater  curvature,  and  the  latter 
tends  to  fall  away  from  the  abdom- 
inal wall  when  the  patient  is  in 
the  dorsal  position.  The  trans- 
verse colon  lies  ordinarily  below 
the  greater  curvature.  With 
moderate  distention,  the  average 
length  from  fundus  to  pylorus  is 
10  to  12  inches;  from  the  lesser  to 
greater  curvature,  4  to  5  inches; 
from  the  anterior  to  the  posterior 
wall,  about  3  to  3^2  inches. 

The  average  capacity  is  vari- 
able. It  may  contain  even  as 
much  as  2  quarts.  A  plane  drawn 
transversely  through  the  base  of 
the  lesser  curvature  will  lie  parallel 
with  the  plane  of  the  diaphragm. 

The  lesser  omentum  extends 
from  the  lesser  curvature  to  the 
liver  above,  and  the  great  omen- 
tum is  suspended  from  the  greater 
curvature,  protecting  the  viscera. 

The  blood-vessels  enter  the 
upper  and  lower  borders,  and  thus 
divide  the  surface  into  two  equal 
parts.  They  mark  the  greater  and 
lesser  curvatures. 

Structure  of  the  Stomach. — The  stomach  consists  of  four  coats: 
serous  or  peritoneal,  muscular,  submucous  or  areolar,  and  mucous.  The 
peritoneal  coat  forms  a  thin,  transparent,  elastic  membrane,  and  closely 
covers  the  organ,  except  along  the  curvatures,  where  it  is  more  loosely 
attached  for  the  passage  of  the  blood-vessels. 

The  muscular  coat  consists  of  three  sets  of  fibers  (Fig.  2),  disposed 
in  layers — the  outer  or  longitudinal,  middle  or  circular,  and  inner  or 
oblique.  The  last  is  a  continuation  of  the  circular  fibers  of  the  esopha- 
gus and  the  fibers  descend  obliquely  from  the  cardia  upon  the  anterior 
and  posterior  surface,  and,  spreading  out  like  a  fan,  terminate  at  the 
greater  curvature. 


Fig.  2. — Vertical  section  of  the 
stomach:  i,  Muc&sa;  2,  submucosa;  3, 
4,  muscularis;  5,  serosa. 


20  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

The  submucous  coat  consists  of  areolar  tissue,  connecting  the  mucous 
and  muscular  coats.     The  blood-vessels  subdivide  therein. 

The  mucous  membrane  is  soft,  smooth,  somewhat  pulpy,  and  of 
pink  color,  thickest  in  the  pyloric  region  and  thinnest  at  the  fundus.  It 
constitutes  the  glandular  layer  of  the  organ.  It  is  covered  by  columnar 
epithelial  cells,  which  extend  for  a  variable  distance  into  the  mouths  of 
the  glands.  There  are  about  five  million  glands  in  the  stomach,  tubular 
in  form,  and  perpendicular  to  the  surface.  They  are  surrounded  by 
fibrous  tissue  and  lymphoid  cells  and  by  a  thin  muscle  layer  (muscularis 
mucosae). 

The  glands  are  composed  of  a  mouth,  neck,  body,  and  base,  and 
several  tubules,  from  two  to  even  four  or  five,  may  end  in  one  mouth. 
On  microscopic  examination,  the  dots  appearing  on  the  surface  of  the 
mucosa  are  the  openings  of  the  glands.  There  are  three  varieties  of 
glands  in  the  stomach: 

Cardiac  or  fundus  glands;  pyloric  glands;  mucous  glands. 

Cardiac  or  fundus  glands  are  the  most  numerous.  They  fill  the  greater 
part  of  the  stomach,  and  are  characterized  by  the  shortness  of  their 
mouths  and  the  length  of  the  glands.  They  contain  two  varieties  of 
cells.  Cells  bordering  on  the  lumen  of  the  tube,  which  are  small,  granular, 
and  polyhedral  or  columnar,  the  chief  or  principal  cells,  and  which  stain 
only  to  a  slight  extent  with  anilin  dyes.  The  other  cells,  parietal  or 
oxyntic,  lie  between  the  principal  cells  and  the  membrana  propria  (Fig. 
3).  They  are  most  numerous  in  the  necks  of  the  glands,  larger  than  the 
chief  cells,  are  oval  or  ajigular,  and  finely  granular  in  structure.  They 
have  strong  affinity  for  anilin  dyes. 

Pyloric  Glands. — These  are  characterized  by  the  greater  length  of 
their  mouths,  which  are  lined  by  cylindric  epithelium.  They  are  found 
only  in  the  region  of  the  pylorus.  The  body  or  secretory  portion  of  the 
gland  is  represented  by  a  single  layer  of  short  and  finely  granular  columnar 
cells,  resembling  the  chief  cells  of  the  fundus  glands.  There  are  also  a 
few  isolated  cells  (Nussbaum)  which  resemble,  in  structure  and  in  their 
behavior  to  anilin  dyes,  the  parietal  cells  of  the  fundus  glands  (Fig.  4). 

Besides  these  specific  glands,  a  number  of  mucous  glands  are  found  near 
the  pylorus. 

The  hydrochloric  acid  is  secreted  by  the  parietal  cells:  pepsin  and 
the  milk-curdling  ferment  by  the  principal  cells  of  the  fundus  and  pyloric 
glands.  Some  consider  the  mucus  to  be  also  a  product  of  the  cylindric 
goblet-cells  lining  the  stomach  and  the  wider  portions  of  the  glandular 
ducts.  The  ferments  do  not  exist  as  such  in  the  cells,  but  as  zymogens, 
which  are  transformed  into  ferments  through  the  activity  of  the  free 
hydrochloric  acid. 

Blood-vessels,  Lymphatics,  and  Nerves  of  the  Stomach. — The  arteries 
of  the  stomach  are  derived  from  branches  of  the  celiac  axis,  the  gastric 
and  pyloric  branches  of  the  hepatic  artery  supplying  the  upper  curvature, 
and  forming  the  superior  ventricular  arch,  and  the  right  gastro-epiploic 
from  the  hepatic,  and  the  left  gastro-epiploic  and  vasa  brevia  from  the 
splenic,  forming  the  inferior  ventricular  arch. 

They  reach  the  stomach  between  the  folds  of  peritoneum  and  ramify 


ANATOMY    OF    THE    STOMACH    AND    INTESTINES 


21 


between  the  muscular  coats,  giving  off  a  number  of  capillaries  and  divid- 
ing into  small  vessels  in  the  submucosa,  and  finally  enter  the  mucous 
membrane  and  pass  between  the  tubuh,  where  they  form  a  plexus  of  fine 
capillaries  both  on  the  walls  of  the  tubules  and  around  the  mouths  of 
the  glands. 

The  veins  arise  from  this  capillary  network  and  pass  nearly  straight 
through  the  mucous  membrane  between  the  glands.  They  pierce  the 
muscularis  mucosae  and  form  a  plexus  in  the  submucosa,  and  finally  form 
the  coronary  and  pyloric  veins  emptying  into'  the  portal  vein,  the  right 
gastro-epiploic  vein  emptying  into  the  superior  mesenteric  vein,  and  the 
left  gastro-epiploic  vein  emptying  into  the  splenic  vein. 


Fig.  3. — Cardiac  gland:  a,  Parietal  cells;      Fig.  4. — Pyloric  gland:  a,  Mouth;  b,  neck;' 
b,  principal  cells.  c,  fundus. 


The  lymphatics  extend  directly  to  the  surface  of  the  mucosa.  They 
form  a  dense  network  of  lacunar  spaces  between  and  among  the  gland 
tubuli,  which  they  inclose,  as  well  as  the  blood-vessels,  with  sinus-like 
dilatations.  The  lymph  is  collected  near  the  surface  of  the  mucous 
membrane  into  vessels  which  form  loops  and  possess  dilated  extremities. 
They  are  less  superficial  than  the  capillaries,  though  the  lacunar  spaces 
extend  as  far  as  the  basement  membrane  of  the  surface.  The  lymphatic 
glands  extend  along  the  lesser  curvature  to  the  cardia,  while  they  are 
present  on  the  greater  curvature  from  the  pylorus  to  only  about  one- 
fourth  to  one-third  of  the  distance.     This  fact  is  of  important  consideration 


22  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

in  gastrectomy  for  carcinoma,  as  the  lesser  curvature  must,  therefore, 
be  entirely  removed. 

Nerves. — The  left  vagus  supplies  the  anterior  surface  of  the  stomach. 
The  right  vagus  supplies  the  posterior  surface  with  only  one-third  of  its 
fibers,  the  remainder  passing  to  the  other  viscera. 

Branches  of  the  sympathetic  nerves  pass  from  the  celiac  plexus  and 
anastomose  with  the  vagi.  These  nerves,  with  numerous  ganglia,  form 
a  network  in  the  submucosa. 

ANATOMY  OF  THE  INTESTINES 

The  intestinal  canal  is  divided  into  two  parts:  the  small  intestine  and 
the  large  intestine;  the  former  about  7.6  meters  (25  feet)  long,  and  the 
latter  1.5  to  1.8  meters  (s  to  6  feet)  long. 

The  small  intestine  is  subdivided  into  three  portions — the  duodenum, 
jejunum,  and  ileum — and  lies,  excepting  the  duodenum,  to  the  inner 
side  of  the  large  intestine,  and  is  connected  to  the  posterior  abdominal 
wall  by  the  mesentery,  which  last  incloses  the  jejunum  and  ileum 
throughout. 

The  Duodenum. — The  duodenum,  which  is  about  10  to  12  inches 
(25.5-30.5  cm.)  long,  is  not  suspended  by  the  mesentery,  and  is  the 
most  fixed  and  widest  part  of  the  small  intestine,  having  a  diameter 
of  i}.^  to  2  inches  (3.81-5.08  cm.).  It  is  curved  like  a  horseshoe,  surrounds 
the  pancreas,  and  is  divided  into  four  parts  (Fig.  5). 

The  superior  horizontal  part  of  the  duodenum  is  about  2  inches  (5.08 
cm.)  long,  begins  at  the  pylorus  at  the  level  of  the  first  lumbar  vertebra, 
and  passes  slightly  upward  and  to  the  right  of  the  gall-bladder.  It  is 
the  most  movable  portion,  is  surrounded  by  the  peritoneum,  and  sus- 
pended chiefly  by  ligaments  from  the  hilus  of  the  liver  and  neck  of  the 
gall-bladder.  The  quadrate  lobe  and  neck  of  the  gall-bladder  lie  above 
it;  below  it  is  the  pancreas,  and  behind  it  the  common  bile-duct  and 
hepatic  vessels. 

The  descending  portion  of  the  duodenum,  about  3  inches  (7.5  cm.) 
long,  commences  at  the  neck  of  the  gall-bladder  and  runs  vertically  to 
the  third  or  fourth  lumbar  vertebra  on  the  right  side,  and  touches  the 
right  kidney.  The  transverse  colon  passes -in  front  of  it;  on  the  left  side 
*is  the  pancreas,  and  the  common  bile-duct  lies  a  little  posterior.  At  its 
inner  and  back  part,  about  4  inches  from  the  pylorus,  the  common  bile- 
duct  and  pancreatic  duct  enter  it  and  form  the  diverticulum  or  ampulla 
of  Vater,  and  the  duct  of  Santorini  enters  it  a  short  distance  above. 

The  third  or  transverse  portion  of  the  duodenum,  about  5  inches 
(12.5  cm.)  long,  extends  from  the  right  side  of  the  body  of  the  third  or 
fourth  lumbar  vertebra  across  the  spine,  and  slightly  ascends  to  the 
left  side  of  the  spine.  The  superior  mesenteric  vessels  cross  it,  as  does 
the  mesentery.  The  lower  layer  of  transverse  mesocolon  lies  in  front. 
The  pancreas  and  superior  mesenteric  artery  lie  above,  and  the  aorta, 
vena  cava,  and  crura  of  the  diaphragm  behind  it.  It  is  the  most  fixed 
portion  of  the  duodenum. 

The  fourth  or  ascending  portion  of  the  duodenum,  about  i  to  2  inches 


ANATOMY    OF    THE    STOMACH    AND    INTESTINES 


23 


(2.54-5.08  cm.)  long,  ascends  vertically  along  the  left  side  of  the  spine, 
from  the  third  or  fourth  lumbar  vertebra  to  the  side  of  the  second  or  first 
lumbar  vertebra.  It  is  firmly  fixed  by  the  suspensory  muscle  of  the 
duodenum  (muscle  of  Treitz),  which  descends  from  the  left  crus  of  the 
diaphragm.  Anteriorly  are  the  transverse  colon  and  transverse  meso- 
colon (lower  layer).  It  terminates  in  the  jejunum  (usually  opposite  the 
second  lumbar  vertebra)  and  forms  the  duodenojejunal  flexure. 

Jejunum  and  Ileum. — They  form  the  continuation  of  the  duodenum. 
It  is  hard  to  determine  where  the  one  ends  and  the  other  begins.  The 
jejunum  occupies  the  upper  two-fifths  of  the  remaining  small  intestines, 


1 


Fig.  5- 


-Stomach  and  duodenum,  liver  and  intestines  removed,  and  showing  anatomic 
relations  of  the  duodenum  (after  Testut). 


or  about  9  feet  7  inches  (2.9  meters) ;  the  ileum,  the  lower  three-fifths,  or 
about  14  feet  5  inches  (4.3  meters),  and  ends  at  the  ileocecal  junction. 
Their  position  is  not  fixed,  but  the  jejunum  is  more  apt  to  occupy  the 
left  side  of  the  abdominal  cavity,  with  the  loops  more  transverse;  while 
the  ileum  is  usually  found  on  the  right  side  and  in  the  pelvis,  with  the 
loops  more  vertical. 

The  coils  of  the  jejunum  and  ileum  are  very  movable  and  are  com- 
pletely invested  by  peritoneum.  They  are  supported  and  attached  to 
the  posterior  parietes  by  the  mesentery,  which  is  attached  above  to  the 
left  of  the  vertebrae  on  a  level  with  the  lower  border  of  the  pancreas. 


24  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

The  mesentery  runs  downward  and  to  the  right  and  presents  the  form  of  a 
fan,  the  intestines  hanging  on  it  in  the  form  of  coils. 

The  diameter  of  the  jejunum  is  about  iH  inches  (3.81  cm.),  and  this 
gradually  diminishes  in  size  to  the  ileum ;  and  in  this,  in  turn,  the  diameter 
decreases  until  its  entrance  into  the  large  intestine.  The  ileum  passes 
nearly  perpendicularly  into  the  ascending  colon,  its  mucosa  forming  a 
double  valve  (valvula  Bauhini). 

'  The  jejunum  and  ileum  are  the  most  movable  parts  of  the  intestinal 
tract.  They  are  often  met  with  in  hernias,  and  if  pregnancy,  a  tumor, 
or  ascites  are  present,  the  intestines  move  up  and  escape  compression. 

Occasionally  Meckel's  diverticulum  (the  remains  of  the  vitelline  duct), 
a  process  2  or  3  inches  long,  is  given  off  from  the  ileum,  on  an  average  of 
I  to  2  feet  above  the  ileocecal  junction.  It  is  of  importance  in  reference 
to  intestinal  obstruction. 

Arterial  Supply  of  Small  Intestine. — The  duodenum  is  supplied  by 
the  pyloric  branch  of  the  hepatic,  by  the  superior  pancreaticoduodenal 
branch  of  the  gastroduodenal  branch  of  the  hepatic,  and  by  the  inferior 
pancreaticoduodenal  branch  of  the  superior  mesenteric,  and  the  jejunum 
and  ileum  by  the  superior  mesenteric  artery.  They  branch  into  small 
vessels  which  run  through  the  intestinal  wall,  ramify  in  the  submucosa, 
and  form  the  capillary  system  of  the  villi  and  glands. 

Veins., — The  venous  blood  flows  partly  into  the  superior  gastric  vein 
and  partly  into  the  superior  mesenteric  vein,  and  empties  into  the  vena 
porta. 

Lymphatics. — The  lymphatics  are  divided  into  those  of  the  mucous 
membrane  and  muscular  coat,  and  form  plexuses.  They  run  between 
the  folds  of  the  mesentery  and  end  in  the  mesenteric  lacteals,  and  so  on 
into  the  intestinal  lymphatic  trunk  and  thoracic  duct.  They  are  provided 
with  valves  to  prevent  a  backward  flow. 

Nerves. — The  duodenum  is  supplied  by  the  hepatic  plexus,  a  branch 
of  the  celiac  plexus,  with  branches  of  the  right  vagus. 

The  superior  mesenteric  plexus,  formed  by  nerves  from  the  celiac 
plexus,  the  semilunar  ganglia,  and  right  vagus,  supply  the  jejunum  and 
ileum. 

The  nerves  enter  the  intestinal  wall  with  the  blood-vessels  and  form 
a  subserous  net.  They  then. penetrate  the  longitudinal  muscular  fibers 
and  form  between  these  and  the  circular  muscular  fibers  ramifications 
consisting  of  numerous  groups  of  multipolar  cells  (Auerbach's  plexus), 
from  which  fine  branches  supply  the  muscular  tissue.  Other  branches 
penetrate  the  circular  muscular  layer  to  the  submucosa,  where  they 
form  the  submucous  nerve  plexus  (Meissner's  plexus),  and  branches  supply 
the  muscularis  mucosae,  the  muscles  of  the  villi,  and  end  in  the  mucosa. 

Structure  of  the  Small  Intestine. — The  small  intestine  is  composed 
of  four  coats:  serous  or  peritoneal,  muscular,  submucous,  and  mucous 
(Fig.  6). 

The  serous  coat  is  formed  by  the  visceral  layer  of  the  peritoneum. 
The  muscular  coat  consists  of  an  internal  circular  layer  and  an  external 
longitudinal  layer,  the  former  being  considerably  the  thicker. 

They  consist  of  bundles  of  unstriped  muscular  tissue  supported  by 


ANATOMY    OF   THE    STOMACH   AND    INTESTINES 


25 


connective-tissue  fibers.     The  submucosa  consists  of  connective  tissue 
in  which  blood-vessels,  lymphatics,  and  nerves  ramify. 


Fig.  6. — Longitudinal  cross-section  through  the  wall  of  the  small  intestine:  i, 
Mucous  layer;  2,  muscularis  mucosae;  3,  submucous  layer;  4,  muscular  layer;  5,  sub- 
serosa;  6,  serous  layer;  7,  intestinal  villi;  8,  intestinal  glands  (Lieberkiihn);  9,  blood- 
vessels; 10,  solitary  lymph  nodule;  11,  center  of  same. 


The  mucous  membrane  comprises  a  thin  muscular  layer  (muscularis 
mucosae),  containing  circular  and  longitudinal  fibers  and  the  tunica 
propria  of  the  mucous  membrane,  which  is  made  up  principally  of  reticular 
connective  tissue,  with  leukocytes,  glands,  villi,  and  an  epithelial  covering. 

muscular  coat 


^mesentery  x 


Fig.   7.- 


dnular  folds 
(+  intestinal  villi) 

-A  portion  of  the  jejunum  showing  the  circular  folds  or  valvulae  conniventes  of 
Kerkring  (Sobotta). 


The  mucosa  is  of  a  grayish-red  color,  appears  velvety,  and  forms 
crescentic  folds,  set  transversely  to  the  long  axis  of  the  intestine  (valvulae 
conniventes  of  Kerkring,  Fig.  7).     Each  valve  extends  from  one-half  to 


26 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


two-thirds  of  the  circumference  of  the  gut,  and  they  may  be  2  inches 
long  and  >i  inch  wide.  They  begin  a  short  distance  below  the  pylorus, 
at  the  middle  of  the  jejunum  commence  to  diminish  in  size,  and  gradually 
disappear  at  the  lower  part  of  the  ileum.  They  serve  to  increase  the 
absorptive  surface  of  the  mucous  membrane. 

Microscopic  Anatomy  of  tiie  Small 
Intestine. — The  inner  surface  of  the 
small  intestine  is  composed  of  villi  and 
glands,  the  surface  being  covered  by  a 
layer  of  columnar  epithelial  cells,  with 
striated  borders  and  some  goblet-cells. 
The  villi  are  formed  chiefly  by  ele- 
vations of  the  tunica  propria  of  the  mu- 
cous membrane.  Th6y  are  from  0.5 
to  0.7  mm.  in  height  and  about  o.i  to 
0.2  mm.  in  width,  and  number  about 
ten  millions  (Fig.  8). 

Each  villus  has  a  central  space  for 
chyle,  which  cavity  is  covered  with  en- 
dothelial cells  and  connects  with  the 
lymphatics  of  the  mucosa.  The  villus 
has  blood-vessels  and  muscular  fibers  which  a^e  derived  from  the  mus- 
cularis  mucosae.  It  expands  when  filling  up  with  blood,  and  when  the 
muscle  contracts  it  shrinks. 

The  villi  thus  have  an  action  of  suction  and  pumping,  and  also  form 
the  chief  organs  for  absorption  in  the  small  intestine.     Around  the  villi 


Fig.  8. — Mucous  membrane  of 
ileum:  a,  Intestinal  glands  (Lieber- 
kiihn);  h,  intestinal  villi;  c,  solitary- 
lymph  nodule  (follicle). 


Fig.  9.^ — Longitudinal  cross-section  through  wall  of  duodenum:  i,  Mucous  layer; 
2,  muscularis  mucosae;  3,  submucous  layer;  4,  circular  muscular  layer;  5,  longitudinal 
muscular  layer;  6,  intestinal  villi;  7,  intestinal  glands  (Lieberkiihn) ;  8,  Brunner's  duo- 
denal glands;  9,  serous  layer. 

are  numerous  glands;  the  tubular  glands  of  Lieberkiihn  and  the  acinous 
glands  of  Brunner.     The  latter  are  confined  to  the  duodenum. 

The  glands  of  Lieberkiihn  resemble  in  structure  the  tubular  glands 
of  the  stomach,  and  cover  almost  the  entire  surface  of  the  small  and 


ANATOMY   OF    THE    STOMACH    AND    INTESTINES  27 

large  intestine.  Each  tubule  is  from  0.3  to  0.4  mm.  long,  and  opens  with- 
out ramifications.  They  form  the  chief  organ  of  intestinal  secretion  and 
number  over  forty  millions. 

Brunner's  glands  are  found  only  in  the  duodenum  and  are  most  abun- 
dant at  its  commencement,  diminishing  in  number  lower  down.  They 
lie  beneath  the  mucosa,  being  embedded  in  the  submucosa.  They  re- 
semble the  pyloric  glands  of  the  stomach,  but  are  more  branched  and 
convoluted,  and  their  ducts  are  longer.  They  are  lined  with  columnar 
epithelium.  The  duct  of  the  gland  passes  through  the  muscularis  mucosje 
and  opens  on  the  surface  of  the  mucosa  (Fig.  9). 

Solitary  follicles  (or  glands)  are  scattered  throughout  the  mucous 
membrane  of  the  small  intestine  and  are  most  numerous  in  the  lower 
ileum.     They  have  a  diameter  of  2  to  6  mm.  (Fig.  10). 

^  mesentay  x 


*''  circular  folds 

solitary  lymphatic  nodules 

Fig.  10. — A  portion  of  the  ileum  showing  solitary  lymphatic  nodes  (Sobotta). 

The  foUicles  consist  of  a  dense  retiform  tissue  packed  with  lymph- 
corpuscles  and  permeated  by  capillaries.  They  have  no  ducts.  The 
spaces  in  this  tissue  are  continuous  with  lymph-spaces  at  the  base  of  the 
gland  and  the  base  of  the  follicle  is  in  the  submucous  tissue.  The  gland 
enters  the  mucous  membrane,  causing  a  slight  projection  of  its  epithelial 
layer.  Lymph-cells  develop  in  these  folUcles.  ,  There  are  no  villi  on  their 
surface. 

These  follicles  are  scattered  singly  through  the  intestine  as  solitary 
glands,  or  collected  into  groups,  known  as  Peyer's  patches  or  plaques,  or 
as  the  agminate  glands.  These  last  may  be  from  i  to  3  inches  long  and 
H  inch  wide,  usually  oval,  with  the  long  axis  parallel  with  that  of  the 


28 


-DISEASES    OF    THE    STOMACH   AND   INTESTINES 


intestine.  They  lie  generally  opposite  the  attachment  of  the  mesentery, 
are  twenty  to  thirty  in  number,  and  are  found  chiefly  in  the  ileum,  though 
a  few  are  present  in  the  jejunum  (Fig.  ii). 


circular 
folds 


(lifgirgated  lymphatic  nodules      lucscnlery  x 
(Flyer's  patch) 

Fig.  II. — A  portion  of  the  ileum,  cut  open  along  the  line  of  attachment  of  the  mesentery, 
showing  Payer's  patch  and  solitary  lymphatic  nodes  (a)  (Sobotta). 


Fig.  12. — Partial  section  of  colon:  i,  Free  tenia;  2,  tenia  mesocolica;  3,  appendices 
epiploicae;  4,  mucosa;  5,  semilunar  folds;  6,  mesocolon. 

Anatomy  of  the  Large  Intestine. — The  large  intestine,  which  is  about 
5  to  6  feet  (1.5-1.8  meters)  long,  extends  from  the  termination  of  the 
ileum  to  the  anus,  and  is  divided  into  the  cecum  (or  caput  coli),  the  colon, 


ANATOMY    OF    THE    STOMACH    AND    INTESTINES  29 

and  the  rectum.  Its  caliber  is  largest  at  the  cecum,  and  this  gradually 
decreases  until  it  reaches  the  ampulla  of  the  rectum,  when  it  again 
increases  in  size. 

The  large  intestine,  excepting  the  rectum,  is  characterized  by  three 
longitudinal  unstriated  muscular  bands  or  teniae  (Fig.  12),  with  saccula- 
tion of  the  walls  between  these  bands  and  by  the  appendices  epiploicae, 
or  external  pouches  formed  by  the  peritoneal  covering  and  containing 
fat. 

The  circular  muscular  fibers  also  accumulate  in  bands  with  intervals 
between  them,  thus  forming  expansions  or  semilunar  folds  across  the 
colon  (haustra  coK)  (Fig.  13). 

The  cecum  (caput  coH)  is  that  part  of  the  colon  lying  below  the 
ileocecal  valve  (Fig.  14).  It  is  about  3  inches  (7.5  cm.)  broad  and  23^ 
inches  (6.3  cm.)  long,  and  lies  in  the  right  iliac  fossa  above  the  outer  half 
of  Poupart's  ligament,  being  completely  covered  by  peritoneum.  When 
filled,  it  is  situated  close  to  the  abdominal  wall.     The  vermiform  appendix, 

semilunar  folds 


lumen 


omental 
band  " 


free  band 
Fig.  13. — A  segment  of  the  colon  (Sobotta);  haustra  coli. 

a  small  blind  tube,  hollow  nearly  to  the  tip,  is  given  off  generally  from 
the  posterior  and  inner  portion  of  the  caput  coli,  about  ij-fe  inch  (1.7  cm.) 
below  the  ileocecal  valve.  Its  average  length  is  7,%  inches  (9.2  cm.). 
It  may  be  much  shorter  or  longer.  The  diameter  is  about  \i  inch  (6 
mm.)  at  the  base  and  %6  inch  (5  mm.)  at  its  apex.  It  may  be  slightly 
larger  at  the  middle.  It  is  usually  guarded  by  a  valve  (crescentic  fold) 
where  it  enters  the  cecum.  It  has  a  meso-appendix  (mesentery)  only 
extending  about  two-thirds  its  length.  The  position  of  the  appendix  is 
not  fixed  and  it  may  point  in  various  directions.  The  colon  is  depicted 
in  Fig.  32. 

The  ascending  colon,  about  8  inches  (20  cm.)  in  length,  extends  verti- 
cally upward  from  the  cecum  to  the  inferior  surface  of  the  right  lobe  of 
the  liver  to  the  right  of  the  gall-bladder,  at  which  point  it  bends  to  the 
left  (hepatic  flexure).  It  passes  along  the  posterior  abdominal  muscles 
and  lower  part  of  the  right  kidney,  and  is  in  relation  to  the  abdominal 
wall  in  front.  It  is  bound  posteriorly  by  connective  tissue  to  the  muscles, 
and  is  only  covered  by  peritoneum  anteriorly  and  laterally. 


30 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


The  transverse  colon,  with  an  average  length  of  20  inches  (51  cm.), 
extends  from  the  hepatic  flexure  beneath  the  liver  transversely  across  the 
abdominal  wall,  with  a  slightly  downward  and  forward  convexity  at  its 
center,  to  the  spleen  in  the  left  hypochondrium  (splenic  flexure).  It  has 
a  long  mesentery,  transverse  mesocolon,  connecting  it  with  the  posterior 
abdominal  wall,  and  is  the  most  movable  part  of  the  large  intestine. 
It  usually  corresponds  to  a  line  separating  the  umbilical  and  epigastric 
regions.  Formerly  it  was  believed  that  the  normal  transverse  colon  lay 
just  above  the  umbilicus,  but  it  has  been  demonstrated  by  the  a;-rays  that 
a  moderate  degree  of  sagging  is  most  frequent  and  that  in  most  cases  it 
lies  below  the  umbihcus.     This  occurs  frequently  without  any  disturb- 


Jree  band        ascending  colon 


ant.  frenulum 
valve 


post. 
frenulum  of  valve — 

upper  Up  of  valve. 


semilunar  folds'^ 


lower  lip  of  valve 


vermiform  process 
Fig.  14. — The  cavity  of  the  cecum  (Sobotta). 

ances  and  with  no  ptosis  of  the  stomach.  The  liver,  gall-bladder,  greater 
curvature  of  the  stomach,  and  lower  end  of  the  spleen  lie  above  it;  the 
small  intestine  lies  below;  the  descending  duodenum  and  small  intestine 
behind;  the  great  omentum  and  abdominal  wall  in  front. 

At  the  splenic  flexure  below  the  lower  end  of  the  spleen,  the  colon 
turns  downward  (descending  colon).  This  is  about  8K  inches  (21.5 
cm.)  long,  and  extends  from  the  splenic  flexure  vertically  through  the 
left  hypochondriac  and  lumbar  regions  to  the  sigmoid  flexure.  It  is 
covered  anteriorly  and  laterally  by  the  peritoneum,  and  passes  down 
in  front  of  the  left  kidney  and  quadratus  lumborum  and  iliac  muscles, 
to  the  left  iliac  fossa  into  the  sigmoid  flexure. 


ANATOMY   OF    THE    STOMACH   AND    INTESTINES  3 1 

The  sigmoid  flexure  of  the  colon  (S.  romanum)  is  an  S-shaped  curve, 
about  13  inches  (31  cm.)  long,  beginning  at  the  iliac  crest  and  ending 
at  the  brim  of  the  true  pelvis  opposite  the  left  sacro-iliac  articulation. 
The  upper,  or  colic,  limb  tends  down,  inward,  and  forward  toward  Pou- 
part's  ligament,  while  the  lower,  or  rectal,  limb  hangs  down  into  the  true 
pelvis,  where  it  joins  the  rectum.  The  sigmoid  flexure  has  a  complete 
peritoneal  covering,  or  mesentery,  is  very  movable,  and  is  the  narrowest 
portion  of  the  large  intestine. 

The  rectum,  which  is  about  8  to  9  inches  (20-23  cm.)  long,  passes 
from  the  left  sacro-iliac  junction  obliquely  to  the  middle  of  the  sacrum 
and  follows  it  down  to  the  bottom  of  the  pelvis  to  about  i  inch  (2.5  cm.) 
below  the  tip  of  the  coccyx,  where  it  passes  downward  and  backward  to 
end  in  the  anus.     It  is  divided  into  three  portions. 

Only  the  first  part,  3K  inches  (9  cm.),  of  the  rectum  is  completely 
invested  with  peritoneum  (mesorectum),  and  it  is  attached  to  the  sacral 
vertebrae.  The  second  part  is  partially  invested  with  peritoneum  (pouch 
of  Douglas),  which  lies  anteriorly  and  ascends  over  the  bladder  or  vagina. 
The  third  part  has  no  peritoneal  investment. 

The  lower  half  of  the  rectum  passes  between  the  organs  occupying 
the  pelvic  floor  and  is  adherent  to  them  by  connective  tissue.  The 
rectum  is  surrounded  by  connective  tissue  below  the  pouch  of  Douglas. 
It  is  widest  at  the  point  opposite  the  prostate,  there  forming  the  ampulla 
of  the  rectum. 

The  outer  longitudinal  muscular  fibers  of  the  rectum  are  not  arranged 
in  teniae,  as  in  the  colon,  but  are  present  in  all  parts  of  its  circumference. 
The  inner  circular  layer  of  muscle-fibers  increases  in  density  from  above 
downward  and  forms  a  thick  ring  at  the  anal  opening  (the  internal 
sphincter).  The  walls  of  the  rectum  are  connected  at  the  anus  with  the 
spincter  ani  and  levator  ani  muscles,  which  are  of  importance  in  defecation. 

Arterial  Supply  of  the  Cecum  and  Colon. — They  are  the  ileocolic, 
colica  dextra,  and  colica  media  from  the  superior  mesenteric  artery;  the 
colica  sinistra  and  sigmoid  from  the  inferior  mesenteric  artery. 

Veins  of  the  Ceciun  and  Colon.* — These  are  the  superior  and  inferior 
mesenteric,  emptying  into  the  portal  system. 

Lymphatics  of  the  Cecum  and  Colon. — Those  of  the  sigmoid  colon 
empty  into  the  lumbar  glands;  those  of  the  rest  of  the  colon  into  the 
mesenteric  glands. 

Nerves  of  the  Cecimi  and  Colon. — The  cecum,  ascending  colon,  and 
right  half  of  the  transverse  colon  are  supplied  by  the  superior  mesenteric 
plexus,  a  branch  of  the  celiac  plexus.  The  rest  of  the  colon,  including  the 
sigmoid  flexure,  is  supplied  by  the  inferior  mesenteric  plexus,  a  branch 
of  the  aortic  plexus. 

Arterial  Supply  of  the  Rectum. — They  are  the  superior  hemorrhoidal 
(of  the  inferior  mesenteric);  the  middle  hemorrhoidal  (of  the  internal 
iliac);  the  inferior  hemorrhoidal  (of  the  internal  pudic);  branches  from 
the  sacromedia  (of  the  abdominal  aorta);  branches  from  the  sciatic  (of 
the  internal  iliac) ;  in  the  female,  branches  from  the  vaginal. 

Veins  of  the  Rectimi. — They  are  chiefly  from  the  superior  hemor- 
rhoidal, passing  to  the  inferior  mesenteric  and  to  the  portal  system;  part 


32  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

of  the  Other  hemorrhoidal  veins  empty  into  the  internal  iliac  veins,  and 
so  enter  the  general  venous  system. 

Anastomosis  thus  occurs  in  the  rectum  between  the  portal  and  the 
general  venous  system,  and  there  is  a  communication  also  with  the  other 
abdominal  veins. 

Lymphatics  of  the  Rectum. — They  empty  into  the  sacral  and  lumbar 
glands  from  the  rectum;  from  the  anus,  into  the  inguinal  glands. 

Nerves  of  the  Rectum. — The  cerebrospinal  nerves  come  from  the 
sacral  plexus;  the  sympathetic  nerves  from  the  inferior  mesenteric  and 
superior  hypogastric  plexus. 

HISTOLOGY  OF  THE  LARGE  INTESTDfE 

The  large  intestine  (colon),  like  the  small  intestine,  consists  of  four 
coats;  serous,  muscular,  submucous,  and  mucous. 

The  longitudinal  muscular  fibers  of  the  large  intestine,  however, 
are  arranged  in  three  bands  (teniae)  running  along  the  wall,  as  already 
described. 

The  serosa  and  submucosa  resemble  those  of  the  small  intestine  in 
structure. 

The  mucosa  of  the  large  intestine  differs  from  that  of  the  small  intestine 
in  that  the  villi  and  circular  folds  of  Kerkring  (valvulae  conniventes) 
are  absent.  The  glands  of  Lieberkiihn  are  somewhat  longer  and  at 
times  curved. 

The  mucous  membrane  of  the  rectum  is  thicker,  redder,  and  more 
generously  supplied  with  blood-vessels  than  that  of  the  colon. 

When  the  rectum  is  empty,  the  mucous  membrane  of  the  upper  part 
is  thrown  into  a  multitude  of  superficial  transverse  velvety  folds.  From 
two  to  seven  folds  (Houston's  valves)  are  made  more  prominent  by  dis- 
tention (Gant). 

Just  above  the  anus  are  a  number  of  longitudinal  folds  (columns  of 
Morgagni),  extending  for  H  to  %  inch  (8.46-15.23  mm.). 

The  mucous  membrane  of  the  rectum  consists  of  columnar  epithelium, 
except  at  the  lowest  portion,  a  narrow  layer  of  stratified  pavement-like 
epithelium,  transitional  between  skin  and  rectal  mucosa.  The  upper 
part  of  the  rectum  resembles  the  colon. 


CHAPTER  II 
PHYSIOLOGY  OF  DIGESTION 

The  stomach  and  intestines  form  an  important  part  of  the  digestive 
tract,  and  in  order  to  understand  their  functions  it  will  be  necessary  to 
review  briefly  the  process  of  digestion.  This  term  includes  those  processes 
which  convert  the  food  into  such  condition  that  it  becomes  fit  to  enter 
the  circulation  and  afford  nutrition  to  the  human  organism.  These 
changes  are  brought  about  by  means  of  certain  ferments  contained  in 
the  saliva,  gastric  juice,  bile,  pancreatic  juice  and  intestinal  juice,  which 
are  a  part  of  the  human  organism  at  birth. 

There  are  certain  fermentative  and  putrefactive  processes  which  take 
place  in  the  gastro-intestinal  canal,  the  result  of  bacterial  invasion, 
which  play  an  important  part  in  the  physiology  and  pathology  of  this 
tract. 

The  first  ferment  (ptyalin)  with  which  the  food  comes  in  contact  by 
the  act  of  chewing,  is  found  in  the  saliva.  The  latter  is  alkaline  in  reaction, 
of  low  specific  gravity  (1.002  to  1.0009),  and  contains  water,  ptyalin, 
mucus,  epithelia,  albumin,  and  salts. 

The  ptyalin,  which  converts  starch  into  maltose,  or  sugar,  begins  its 
action  on  the  food  already  in  the  mouth,  but  the  principal  work  is  done 
during  the  first  period  of  digestion  within  the  stomach.  The  food  passes 
into  the  fundus  and  accumulates  there  to  form  a  mass,  and  it  is  not  until 
twenty  to  thirty  minutes  later  that  the  first  movements  of  the  stomach 
begin  to  appear.  Under  normal  conditions  during  this  early  stage  of 
gastric  digestion  the  free  hydrochloric  acid  is  becoming  combined  acid, 
and  the  action  of  the  ptyalin  continues;  but  if  the  free  hydrochloric'  acid 
be  excessively  secreted,  further  digestion  of  the  starch  is  interfered  with; 
this  physiologic  fact  has  a  bearing  on  the  treatment  of  hyperchlorhydria. 
We  must  remember  that  thorough  mastication  of  the  food,  which  promotes 
salivary  secretion,  and  the  care  of  the  teeth  have  an  important  bearing  on 
digestion.  It  has  been  demonstrated  that  acid  fermentation  in  the  mouth 
interferes  with  the  action  of  the  saliva,  and  that  cleansing  the  mouths  of 
nursing  infants  will  diminish  fermentative  processes  in  the  gastro-intestinal 
tract. 

Hemmeter  has  apparently  recently  demonstrated  on  dogs  that  the 
salivary  glands  secrete  a  chemical  substance  (a  hormone)  during  mastica- 
tion which  passes  into  the  blood  and  starts  up  the  secretion  of  the  gastric 
juice.  After  extirpation  of  the  glands,  HCl  and  rennin  were  much 
reduced.  Intravenous  injection  of  salivary  gland  extracts  partially 
restored  gastric  secretion. 

THE  GASTRIC  JUICE 

Hydrochloric  acid  was  discovered  in  the  gastric  juice  by  Prout  in 
1824;  and  Beaumont,  in  1833,  by  his  experiments  on  St.  Martin  with  his 
3  33 


34  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

gastric  fistula,  greatly  advanced  our  knowledge.  Schwam,  in  1836, 
discovered  the  pepsin  ferment;  and  Bedder  and  Schmidt,  in  1854,  showed 
that  the  acid  of  the  gastric  juice  is  hydrochloric  acid. 

The  gastric  juice  is  a  clear,  colorless  fluid,  of  an  acid  reaction  and 
a  specific  gravity  of  1.002  to  1.003.  It  contains  water,  salts,  inorganic 
matter,  proteins,  hydrochloric  acid,  pepsin,  rennet,  and  recently  a  fat- 
splitting  ferment  has  been  discovered  (lipase).  There  is  also  a  peri- 
staltic hormone. 

The  quantity  of  this  secretion  in  twenty-four  hours  is  estimated  to 
be  about  3  pints.  The  degree  of  acidity  varies  from  o.i  to  0.2  per  cent. 
Pepsin  and  rennet  when  first  secreted  are  inactive  bodies,  known  as 
pepsinogen  and  rennet-zymogen,  but  on  coming  into  contact  with  the 
hydrochloric  acid  become  converted  into  active  pepsin  and  rennet.  Vari- 
ous theories  have  been  advanced  to  explain  the  production  of  the  gastric 
juice,  how  an  inorganic  acid  comes  to  be  secreted  by  the  blood  which  is  of 
alkaline  reaction.  We  are  so  far  forced  to  accept  the  view  that  the  secre- 
tion of  the  gastric  juice  must  be  due  to  the  specific  action  of  the  cells. 

Through  the  combined  action  of  hydrochloric  acid  and  pepsin,  it  con- 
verts the  albuminates  into  propeptones  and  peptones,  which  are  more 
soluble.  The  rennet  ferment  curdles  the  milk.  A  small  percentage 
of  emulsified  fat,  as  in  milk,  is  split  into  fatty  acids  by  lipase,  a  fat 
splitting  ferment  of  the  stomach. 

The  gastric  juice  has  the  property  of  converting  cane-sugar  into  grape- 
sugar,  and  gelatin  into  a  soluble  peptone  which  does  not  coagulate. 

Some  of  the  substances  contained  in  the  liquefied  chyme  are  absorbed 
through  the  stomach-wall,  such  as  peptone,  sugar,  salts,  and  possibly 
propeptone.  Meltzer  has  demonstrated  that  only  a  small  quantity  of 
water  is  absorbed  in  the  stomach.  The  residue  of  the  gastric  contents 
passes  into  the  small  intestine,  where  further  digestive  processes  occur 
through  the  action  of  the  other  ferments  and  the  principal  absorption 
takes  place. 

Bacteria  in  the  Mouth  and  Gastric  Juice. — Formerly  the  acid  of  the 
stomach  was  looked  upon  as  destructive  to  bacteria.  The  mouth  contains 
many  bacteria  and  the  importance  of  pyorrhea  alveolaris,  naso-pharyn- 
geal  and  tonsillar  infections  to  gastro-intestinal  disturbances,  rheumatic 
and  other  conditions  is  now  coming  to  be  realized.  Many  varieties  of 
bacteria  are  ingested  into  the  stomach  and  are  not  destroyed  by  the  gas- 
tric juice.  Smithies  from  the  microscopic  examination  of  the  gastric 
contents  of  2406  patients  with  gastro-intestinal  disturbances  of  various 
types,  showed  that  irrespective  of  the  degree  of  acidity  of  the  gastric  con- 
tents that  bacteria  were  present  in  87  per  cent.  The  different  varieties 
were  cocci  and  diplococci,  bacilli  short  and  long,  often  of  the  colon  b.  type, 
streptococci  and  staphylococci  and  leptothrix  buccalis.  In  the  saliva  cul- 
ture in  fifty-four  cases,  streptococci  and  staphylococci  were  present  in 
over  80  per  cent.  The  pus-producing  organisms  have  their  proliferation 
retarded  by  the  gastric  juice  but  the  bacilli  (particularly  the  colon  b.) 
and  the  leptothrix  grow  well  in  the  stomach.  Bacteria  furthermore  live 
in  the  small  intestine  or  pass  through  it,  or  enter  the  blood-stream  through 
the  mucosa.  . 


PHYSIOLOGY    OF   DIGESTION 


35 


I.  Secretion  of  the  Gastric  Juice. — Pawlow^  has  discovered  many 
new  facts  relating  to  the  physiology  of  gastric  secretion.  Among  these 
are  the  following:  The  amount  of  gastric  juice  secreted  is  proportionate 
to  the  quantity  of  food  ingested;  the  secretion  is  acid,  and  the  more  rapidly 
it  appears,  the  greater  is  the  quantity  of  acids  produced.  The  gastric 
juice  appearing  after  a  bread  diet  shows  the  most  marked  digestive  activity; 
following  this  is  the  gastric  juice  after  a  meat  diet,  and  the  least  digestive 
activity  is  found  after  a  milk  diet.  Moreover,  every  variety  of  food 
stimulates  a  definite  quantity  of  secretion. 

Quantity  of  Secretion. — The  average  quantity  of  juice  secreted  every 
hour  is  one  and  a  half  times  less  after  a  bread  diet  than  after  a  milk  or  meat 
diet,  the  digestion  consuming  a  longer  period  of  time.  A  latent  period 
occurs  between  the  ingestion  of  food  and  the  appearance  of  the  secretion, 
lasting  from  four  and  a  half  to  ten  minutes.  Nervous  influences  play  an 
important  role  in  the  secretion  of  the  gastric  juice  as  is  demonstrated 
by  the  fact  that  after  feeding  a  dog  in  whom  an  esophagotomy  has  been 
performed  (sham  feeding),  a  certain  quantity  of  gastric  juice  will  appear 
in  the  gastric  fistula  within  a  few  minutes.  The  sensations  of  taste,  smell, 
sight,  and  the  presence  of  food  within  the  mouth  reflexly  stimulate  the 
secretory  nerves  in  the  vagus.  Sham  feeding  has  no  longer  any  influence 
on  the  secretion  of  gastric  juice  if  the  vagus  has  been  severed,  demonstrat- 
ing that  this  is  the  secretory  nerve  of  the  gastric  glands.  As  already  men- 
tioned, the  sight  of  food  will  cause  secretion  of  the  gastric  juice  (appetite 
juice),  since  the  appetite  is  a  strong  stimulant  to  the  secretory  nerves. 
Hertz  and  Sterling,  however,  in  studying  the  psychic  gastric  juice  in  a 
gastrostomy  patient,^  found  that  in  this  case  there  was  not  the  intimate 
correlation  in  the  simultaneous  presence  of  appetite  and  a  flow  of  gastric 
juice,  nor  did  mastication  of  sapid  substances  cause  the  flow  of  an  "  appe- 
tite juice."  They  refused,  however,  to  generalize  from  this  single  sub- 
ject. Pawlow,  moreover,  found  that  further  secretion  of  the  gastric  juice 
is  due  to  certain  substances  contained  in  the  foods,  known  as  secretogogues 
(which  stimulate  further  secretion).  Pure  mechanical  stimulation  is  not 
the  cause.  Meat  juice  and  beef  extracts  are  marked  stimulants  to  the 
flow  of  gastric  juice,  while  milk  is  less  so,  and  water  is  a  weak  stimulant. 
Pawlow  further  claims  that  the  ash  of  meat,  sodium  chlorid,  hydrochloric 
acid,  and  soda  do  not  stimulate  the  secretion,  and  that  egg-albumen  and 
pure  peptone  have  no  effect.  Starch,  cane-sugar,  and  grape-sugar  have 
no  influence,  while  starch  paste  and  meat  extract  together  markedly  in- 
crease this  secretion.  Fats  have  no  influence  on  the  secretion  of  gastric 
juice,  and  when  introduced  with  other  food  diminish  this  secretion. 
Edkins^  claims  that  the  secretogogues,  whether  they  are  preformed  in  the 
food,  or  formed  from  it  in  the  process  of  digestion,  act  upon  the  pyloric 
mucous  membrane  and  form  gastrin  (or  gastric  secretin),  which  is  absorbed 
into  the  blood  and  then  carried  to  the  gastric  glands  to  stimulate  their 
activity.  Starling  shows  that  this  is  similar  in  action  to  the  secretin  in 
producing  pancreatic  secretion.  He  designates  these  internal  secretions 
as  "hormones." 

*  The  Digestive  Glands. 

*  Deutsche  med.  Woch.,  Aug.  4,  1910. 

'  Journal  of  Physiology,  1906,  xxxiv,  p.  133. 


36  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

2.  The  Motor  Function  of  the  Stomach  and  Cap  (Duodenal). — The 
motor  function  of  the  stomach  is  of  importance  in  the  process  of  digestion, 
as  by  its  active  and  passive  movements  physical  changes  are  brought 
about  in  the  ingesta.  The  movements  transmitted  by  the  diaphragm 
and  abdominal  muscles  assist  the  action.  The  food  is  brought  more 
closely  in  contact  with  the  stomach-wall  and  becomes  more  liquefied. 
The  pylorus  opens  and  closes  at  intervals,  and  allows  the  entrance  of  the 
chyme  into  the  small  intestine,  at  an  interval  of  about  twenty  seconds, 
according  to  Cannon,  depending  on  the  acidity  of  the  chyme  and  the 
consistency  of  the  focd.  About  two  to  three  hours  after  a  small  meal, 
and  six  to  seven  hours  after  a  large  meal,  the  stomach  is  empty. 

Cannon^  has  studied  the  movements  of  the  stomach  by  the  x-rays, 
by  administering  food  mixed  with  bismuth,  and  by  observation  with  a 
fluoroscope.  He  found  that  the  contractions  start  in  the  middle  of  the 
stomach  and  pass  toward  the  pylorus  at  regular  intervals.  The  pyloric 
end  of  the  stomach  lengthens  out  and  the  peristaltic  waves  increase 
during  advanced  digestion.  At  intervals  the  pylorus  relaxes  and  the 
contraction  squeezes  part  of  the  chyme  into  the  duodenum. 

He^  found  that  carbohydrates  pass  out  the  soonest  after  ingestion  and 
require  only  about  one-half  the  time  that  proteins  do  for  gastric  digestion. 
If  the  protein  is  given  first,  the  passage  of  the  carbohydrate  will  be  delayed. 
Fat  when  taken  alone  remains  for  a  considerable  time  in  the  stomach,  and 
if  combined  with  other  food,  the  exit  of  the  latter  is  delayed.  It  is  believed 
that  chemic  stimuli,  such  as  hydrochloric  acid,  control  the  opening  and 
closing  of  the  pylorus.  With  achylia  gastrica,  however,  the  motor  func- 
tion of  the  stomach,  in  spite  of  the  absence  of  hydrochloric  acid,  is  fre- 
quently normal.  The  consistency  of  the  chyme,  to  which  Cannon  refers, 
and  possibly  some  new  formed  chemical  constituents,  may  be  responsible 
for  the  regularity  of  the  pyloric  reflex  in  this  case.  Bassler'  has  made 
some  rather  interesting  observations  with  the  x-xzy  in  this  regard. 

Griitzner  and  Cannon'*  have  demonstrated,  moreover,  that  the  waves 
in  the  fundus  are  very  slight  and  do  not  affect  the  contents  in  that  portion 
of  the  stomach  for  a  considerable  period  of  time,  so  that  the  food  lying 
there  does  not  immediately  mix  with  the  acid  gastric  juice.  This  is  an 
important  fact  in  connection  with  the  salivary  digestion  of  the  starches, 
so  that  ptyalin  digestion  may  in  some  cases  continue  for  an  hour,  before 
it  is  inhibited  by  the  acid  gastric  juice.  The  swallowed  food  arranges 
itself  in  co.nsecutive  layers  in  the  stomach.  Physiologic  observations 
apparently  show  that  nature  provides  against  the  danger  of  diluting  the 
gastric  contents  during  digestion  by  the  drinking  of  fluids  during  the  meal; 
since  O.  Cohnheim  observes  that  even  in  a  stomach  containing  considerable 
food,  the  ingestion  of  a  large  quantity  of  fluid  causes  a  separation  of  the 
food  from  the  lesser  curvature,  along  which  the  fluid  passes  rapidly  into 
the  duodenum. 

F.  Hoffmeister,  Schuetz,  Rieder,  B runner,  and  Groedel"  describe 
three  phases  in  the  motor  mechanism  of  the  stomach. 

^  American  Journal  of  Physiology,  1898. 

*  Ibid.,  1904. 

'  Diseases  of  the  Stomach  and  Upper  Alimentary  Tract. 

*  Archiv  f.  die  gesammte  Physiologic,  p.  106,  463. 

*  Archiv  fur  exper.  Pathologic,  xx. 


PHYSIOLOGY   OF   DIGESTION  37 

Motility  of  the  Stomach  and  Duodenal  Cap. — They  divided  the  move- 
ments into  those  occurring  in  the  fundus,  a  sphincter  antri  pylori  pro- 
ducing temporary  occlusion  and  division  of  the  stomach  into  two  parts, 
the  antrum  pylori  (accessory  stomach  and  fundal  portion).  Both  peristal- 
tic and  antiperistaltic  movements  of  the  antrum  were  described.  The 
sphincter  antri  is  now  believed  to  be  merely  the  point  of  maximum  con- 
traction. L.  G.  Cole  interprets  a  "single  peristaltic  contraction  of  the 
stomach"  or  more  correctly  an  "individual  peristaltic  contraction" 
as  the  formation  and  progression  of  a  peristaltic  contraction  from  its 
origin  in  the  fundus  to  the  pylorus,  it  should  not  be  confused  with  the 
formation  and  duration  of  an  individual  antrum  or  gastric  cycle.  The 
individual  contraction  passing  from  the  fundus  to  the  pylorus  usually 
does  not  exceed  ten  seconds,  while  the  single  gastric  cycle  takes  from  two 
to  three  seconds.  The  individual  contraction  is  divided  into  as  many 
gastric  cycles  as  there  are  peristaltic  contractions.  Holzknecht  de- 
scribes a  one-cycle  type  as  the  normal,  having  the  marked  contraction 
known  as  the  sphincter  antri  which  periodically  cuts  off  the  antrum  pylori 
from  the  body  of  the  stomach.  Cole  shows  five  types:  the  one-cycle, 
one-and-a-half-cycle,  two-cycle,  three-  and  four-cycle  type  (the  latter  the 
most  common),  and  a  group  where  more  than  four  cycles  occur  for  the 
progress  of  the  contraction  (choreic  type).  Corresponding  contractions 
occur  in  the  lesser  and  greater  curvatures,  except  in  the  one-and-a-half- 
cycle  type  in  which  there  is  a  second  small  contracture  in  the  lesser  curva- 
ture without  corresponding  contraction  in  the  greater.  With  each  gastric 
•cycle  there  is  a  systole  and  diastole.  The  gastric  cycle  is  governed,  but  not 
entirely  controlled  by  the  vagus  through  the  same  nervous  impulses  which 
govern  respiration,  or  indirectly  by  respiration  itself.  Cannon  believes 
the  opening  of  the  pylorus  to  be  governed  by  the  degree  of  gastric  acidity, 
stage  of  digestion  and  nature  of  the  duodenal  contents.  Cole  imputes 
further  movements  to  contraction  of  the  cap  (the  ascending  duodenum) 
giving  a  broad  propulsive  peristalsis  and  probably  dependent  upon 
changes  in  reaction  of  the  contents  of  the  descending  duodenum. 

If  atony  of  the  stomach  be  present,  motor  insufficiency  and  stasis 
result,  and  the  latter  favors  fermentation  and  putrefaction.  It  has  been 
demonstrated  that  the  presence  of  hydrochloric  acid  in  considerable 
quantities  does  not  prevent  these  conditions  if  stasis  be  present. 

Shape  of  the  Cap  (Duodenal). — The  cap  is  usually  triangular  in  shape 
— with  the  base  parallel  to  and  at  the  pyloric  ring.  At  times,  however,  it 
may  be  square  or  like  a  parallelogram. 

Shape  of  the  Stomach. — There  are  variations  in  the  shape  of  the  stomach  • 
and  yet  all  the  functions,  as  well  as  its  position  may  be  normal.  The  most 
frequent  types  of  stomach  are  the  cow-horn,  text-book,  drain-trap  (water- 
trap)  and  fish-hook.  The  fish-hook  and  drain-trap  frequently  occur  with 
gastroptosis  and  the  possibility  of  these  peculiar  shapes  being  an  accessory 
in  producing  gastroptosis  through  weight  of  the  food  in  the  trap  or  hook 
portion  might  suggest  itself.  Though  the  infant  stomach  directly  after 
birth  was  formerly  believed  to  be  vertical  and  that  it  later  assumed  the 
adult  position,  it  has  been  recently  demonstrated  that  there  is  no  definite 
normal  type  of  stomach  in  the  infant.  Pisek^  and  LeWald  in  their  radio- 
*  American  Journal  Diseases  of  Children,  Oct.,  1913,  vol.  6. 


38  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

graphs  distinguish  the  (i)  ovoid  or  Scotch  bag-pipe  shape;  (2)  the 
tobacco-pouch  or  retort  shape;  and  the  (3)  pear-shaped  stomach.  The 
stomach  was  larger  than  the  ordinary  conception,  and  infant  stomachs 
were  characterized  by  their  rapid  motility — the  food  quickly  escaping 
through  the  pylorus. 

INTESTINAL  DIGESTION 

Under  normal  conditions,  when  the  chyme  enters  the  duodenum 
its  reaction  is  acid.  It  is  here  subjected  to  the  influence  of  the  bile, 
pancreatic  juice,  and  intestinal  secretions,  all  of  which,  in  their  action, 
have  a  more  or  less  close  interdependence  upon  each  other. 

Bile. — The  bile  in  the  intestine  precipitates  the  pepsin  from  the 
chyme.  This,  however,  is  soon  dissolved.  Others  hold  that  albuminoids 
are  precipitated  from  the  chyme,  together  with  the  pepsin,  and  are  then 
more  readily  absorbed.  It  does  not  have  a  deleterious  effect  on  the 
pancreatic  digestion.     Bile  contains  a  weak  amylolytic  ferment. 

The  bile  is  one  of  the  chief  factors  in  gradually  altering  the  reaction 
of  the  chyme  to  neutral  or  alkaline,  and  it  strongly  supplements  the  action  of 
the  pancreatic  juice  in  emulsifying  fats,  aiding  their  absorption  and  its 
absence  or  diminution  lessens  this  function. 

Roger^  and  Chabanier  hold  it  enhances  the  starch  splitting  of  the 
pancreatic  juice,  activates  the  lactase  of  the  intestinal  secretion,  and 
exerts  a  tractor  influence  by  drawing  forth  certain  ferments  contained  in 
the  cells  of  the  intestinal  epithelium — particularly  invertin.  It  aids  in 
the  digestion  of  proteins  which  last  tend  to  form  in  an  acid  medium  cer- 
tain insoluble  compounds  with  the  bile.  The  precipitates  thus  formed 
redissolve  in  an  excess  of  bile. 

Pawlow  believes  that  it  may  augment  slightly  the  effects  of  the  other 
pancreatic  ferments. 

One  of  its  chief  functions  is  undoubtedly  excretory,  and  through  it 
many  of  the  useless  products  of  metabolism  are  eliminated.  When  ab- 
sorbed into  the  system  it  acts  as  a  poison  and  produces  a  definite  toxemia. 

The  bile  is  a  clear,  tenacious  mucoid  fluid  with  an  alkaline  reaction, 
consisting  of  water,  bile-acid  salts  (glycocholic  and  taurocholic  acid), 
pigments  (bilirubin  and  biliverdin),  mucin,  cholesterin,  lecithin,  soaps, 
fats,  etc.;  about  500  to  600  c.c,  are  excreted  in  twenty-four  hours. 

Wm.  H.  Porter^  beUeves  that  the  precipitation  of  the  pepsin  from 
the  chyme  through  the  action  of  the  bile  is  necessary  for  the  action  of  the 
pancreatic  ferments,  and  the  enterokinase  of  the  intestinal  juice,  as  the 
pepsin,  as  long  as  it  remains  active,  inhibits  their  action. 

Some  consider  that  it  has  antifermentative  and  antiputrefactive 
powers,  and  that  it  helps  to  maintain  the  nutrition  of  the  epithelial  cells. 
Lindenberger  has  shown  experimentally  that  a  small  amount  of  bile  com-, 
bined  with  0.05  per  cent,  of  lactic  acid  prevents  putrefaction  in  an  infusion 
of  pancreas,  while  lactic  acid  alone  has  no  effect. 

Von  Noorden  holds  that  bile  has  no  antiseptic  action. 

^  Universal  Medical  Record,  April,  1913. 

2  Indicanuria  a  Danger  Signal,  Postgraduate,  1907. 


PHYSIOLOGY    OF   DIGESTION 


39 


Roger  shows  that  it  checks  putrefaction. '^  It  favors^  propagation  of 
the  colon  bacillus  and  inhibits  growths  of  the  anaerobic  agents  of  putre- 
faction. It  exercises  an  antitoxic  function  by  neutralizing  certain  poisons 
arising  from  intestinal  putrefaction.  Mucin  is  coagulated  by  a  ferment — 
(mucinase)  contained  in  the  intestinal  cells.  Bile  inhibits  this  action  so 
that  mucus  contained  in  the  upper  part  of  the  intestine  is  in  a  liquid  state. 
When  mucus  coagulates,  it  occurs  in  the  lower  part  of  the  intestine  where 
there  is  the  least  amount  of  bile.  He  attributes  pseudomembranous 
enteritis  (mucous  colic)  partly  to  biliary  insufficiency  the  other  factors 
being  an  excess  of  mucus  and  mucinase,  administering  ox  gall  for  treat- 
ment of  such. 

Clinically,  we  at  times  see  cases  of  indicanuria  with  the  presence  of 
bile  in  the  urine  and  with  light-colored  stools  in  whom  there  is  no  perma- 
nent disappearance  of  indican,  though  there  is  a  temporary  improvement 
after  the  use  of  calomel,  etc.,  until  the  biliary  excretion  into  the  intestine 
is  restored  to  normal.  The  internal  use  of  the  bile-salts,  which  can  be 
given  as  inspissated  bile,  seems  to  be  of  some  value.  Bile  stimulates 
the  functions  of  the  liver  and  possesses  slightly  purgative  qualities  by 
increasing  peristalsis. 

The  liver  has  special  functions.  Many  of  the  substances  taken  up  by 
the  digestive  process  are  stored  there  until  used  in  the  system,  namely, 
some  of  the  peptones  and  sugar  in  the  form  of  glycogen.  It  excludes  some 
poisonous  matters  from  the  circulation.  Thus  it  is  the  chief  organ  for 
the  removal  of  indol  and  poison,  such  as  curare  or  of  various  autotoxins. 
Urea  is  also  formed  in  the  liver. 

Pancreatic  Juice. — The  pancreatic  juice  is  the  principal  factor  of  diges- 
tion in  the  intestinal  canal.  It  is  clear,  colorless,  alkaline,  sticky  and 
odorless,  quite  albuminous,  containing  water,  solids,  proteins,  and  inor- 
ganic matter. 

The  most  important  constituents  are  the  three  ferments: 

Amylopsin,  an  amylolytic  enzyme,  which  converts  starch  into  dextrin 
and  maltose,  and  still  further  into  glucose.  Cane-sugar  is  converted 
into  grape-sugar,  while  milk-sugar  is  unchanged.  Some  of  the  cellulose 
ferments  form  marsh-gas  and  various  acids.  The  activity  of  pancreatic 
diastase  is  increased  by  very  small  quantities  of  acids  (Chittenden). 

Steapsin,  a  lipolytic  ferment.  This  acts  upon  fats  by  splitting  them 
into  fatty  acids  and  glycerin;  and  this  action  is  increased  by  the  bile. 
The  fatty  acids  combine  with  the  alkalis  in  the  intestines  to  form  soaps, 
which  aid  in  the  emulsifying  of  fats,  and  thus  promote  their  absorption. 
The  emulsification  occurs  in  an  alkaline  medium,  or  in  contact  with  the 
alkaline  secretion  of  the  mucous  membrane. 

Trypsin,  a  proteolytic  ferment,  changes  the  proteins  into  albumoses 
and  peptones.     There  is  probably  a  rennet-zymogen  also. 

The  trypsin  ferment  acts  in  a  neutral  or  alkaline  medium,  though  slight 
degrees  of  acidity  seem  to  favor  it.  Indol  is  a  product  of  intestinal 
putrefaction,  and  not  from  the  action  of  the  pancreatic  ferment,  as  was 
formerly  supposed.     The  same  is  true  of  hypoxanthin.     Some  hold  there 

^  Med.  Record,  June  14,  1913. 
*La  Presse  Medicale,  Oct.  2,  191 2. 


40  DISEASES    OF    THE    STOMACH    AXD    INTESTINES 

is  a  lab  ferment  and  a  ferment  ''nuclease."  (See  Section  on  the  Pan- 
creas.) There  is  an  internal  secretion  of  the  pancreas  influencing  the 
metabolism  of  sugar. 

The  secretion  of  the  pancreatic  juice  is  not  reflex,  but  is  due  to  direct 
excitation*  of  the  cells  of  the  pancreas  by  secretin  (Starling).  This  is 
formed  from  "prosecretin"  in  the  mucous  membrane  of  the  duodenum 
and  jejunum  and  reaches  the  pancreas  by  the  blood-stream.  The  passage 
of  the  hydrochloric  acid  in  the  chyme  over  these  portions  of  the  small 
intestine  stimulates  the  production  of  secretin  or,  rather,  splits  it  oflf  from 
the  prosecretin,  which  is  present  in  the  mucous  membrane. 

Some  of  the  French  physiologists  claim  that  the  secretin  also  stimulates 
the  production  of  prosecretin  and  the  functional  activity  of  the  liver  and 
jejunum  (the  succus  entericus).  Probably  the  spleen  produces  a  similar 
hormone  which  stimulates  the  digestive  glands  and  has  a  part  in  the 
activation  of  trypsinogen.  Secretin  is  said  also  to  influence  (increase) 
the  motility  of  the  bowel. 

The  intestinal  juice  (succus  entericus)  consists  of  water,  albumin, 
mucin,  and  salts.  It  seems  to  neutralize  the  acids  formed  by  the  fermen- 
tation of  the  carbohydrates,  and  the  presence  of  mucin  shows  it  to  be  of 
service  in  aiding  peristalsis. 

Pawlow's  experiments  demonstrate  that  it  augments  the  activity  of 
the  pancreatic,  ferments,  especially  of  trypsin.  The  fat-splitting  and 
amylolytic  pancreatic  ferments  are  augmented  by  the  succus  entericus 
from  all  parts  of  the  small  intestine,  while  that  from  the  duodenum  aug- 
ments chiefly  the  proteolytic  ferment.  Ptyalin  and  several  enzymes  have 
been  found  in  the  intestinal  juice. 

The  intestinal  juice  contains  three  enzymes  acting  on  the  carbo- 
hydrates: Maltose,  which  acts  on  maltose;  invertin,  which  acts  on 
cane-sugar;  and  lactose,  which  acts  on  milk-sugar. 

Pawlow  found  enterokinase,  a  ferment  of  other  ferments,  which  is 
believed  to  be  necessary  to  excite  intestinal  ferments  into  activity.  It 
probably  acts  chiefly  in  converting  trypsinogen  into  trypsin. 

Erepsin,  another  ferment,  is  also  present,  which  transforms  hemi- 
albumose  into  other  bodies,  completing  the  work  of  the  pepsin  and 
trypsin. 

Organized  Ferments. — There  exist  in  the  intestines  fermentative  and 
putrefactive  changes  produced  by  microorganisms.^  At  birth  the  gastro- 
intestinal tract  is  sterile,  but  rapidly,  by  the  ingestion  of  food  and  through 
the  air  and  by  the  anus,  bacteria  of  various  types  enter  this  tract. 

Herter^  has  estimated  their  number  at  one  hundred  and  twenty-six 
billions  for  the  daily  human  excreta.  Many  of  them  are  no  longer  living. 
He  considers  the  chief  function  of  the  obligate  bacteria  (Bacillus  lactis 
aerogenes,  Bacillus  coli,  and  Bacillus  bifidus)  to  be  their  capacity  for 
checking  the  development  of  other  types  of  organisms  capable  of  doing 
injury,  though  they  themselves  under  certain  conditions  may  produce  much 
harm.     Many  other  varieties  are  described.     Some  observers  believe  that 

*  Proceedings  American  Medico-Psych.  Association,  April  21,  1905.  Some  Ob- 
servations on  the  Relations  of  the  Gastro-intestinal  Tract  to  Nervous  and  Mental 
Diseases  (Kemp). 

'  Bacterial  Infections  of  the  Digestive  Tract. 


PHYSIOLOGY    OF    DIGESTION  4I 

there  is  a  so-called  normal  fermentative  process  which  aids  in  the  digestion 
of  cellulose,  though  Bergman  claims  there  are  enzymes  (intracellular) 
which  decompose  it. 

The  fermentative  processes  in  the  small  intestine  caused  by  the  action 
of  bacteria  on  the  carbohydrates  (Bacillus  lactis  aerogenes)  leads  to  the 
formation  of  ethyl  alcohol  and  various  organic  acids,  such  as  lactic,  acetic, 
paralactic,  succinic,  biliary  acids  and  albumin,  peptone,  mucin,  sugar, 
etc.  These  organic  acids  are  believed  to  prevent  putrefaction  within  the 
intestines,  to  partly  check  the  decomposition  of  the  carbohydrates,  and 
to  aid  in  producing  intestinal  peristalsis,  which  render  putrefaction  less 
likely.  The  lactic  acid  in  koumyss,  matzoon,  bacillac  and  lactone  butter- 
milk, and  even  in  plain  milk  (to  a  slighter  degree),  is  believed  to  lessen 
putrefaction.     In  the  lower  jejunum  and  ileum  the  reaction  is  acid. 

When  the  intestinal  contents  pass  into  the  colon  the  reaction  becomes 
alkaline,  fermentation  stops,  putrefaction  begins,  and  the  fecal  odor 
appears.  The  colon  bacilli  are  marked  factors  in  this  process.  The 
decomposition  of  the  albuminates  caused  by  bacteria  goes  much  further 
than  that  produced  by  pancreatic  digestion.  Albumoses,  peptones, 
lysin,  ammonia,  amido-acids,  etc.,  are  produced  in  both  cases,  but  with 
putrefaction  the  process  goes  further  and  we  have  new  products  formed, 
such  as  indol,  skatol,  paracresol,  phenol,  various  acids  and  gases,  such  as 
sulphuretted  hydrogen,  marsh-gas,  carbon  dioxid,  etc. 

Some  of  these  products  of  decomposition  are  eliminated  unchanged 
in  the  urine,  such  as  the  oxyacids,  others,  like  the  phenols,  after  further 
oxidation;  others,  like  indol  and  skatol,  after  combination  with  ethereal 
sulphuric  acids.  For  example,  indol  forms  an  indoxyl-potassium  sulphate 
or  indican,  and  is  so  eliminated  in  the  urine;  and  thus  may  be  an  indica- 
tion of  the  amount  of  putrefaction  occurring  in  the  intestines. 

The  causes  of  indicanuria  are  various,  such  as  excessive  protein  diet, 
catarrh  of  the  small  intestine  causing  alterations  in  the  mucosa  and  in- 
creased intestinal  putrefaction  therefrom,  typhoid,  cholera,  a  pus-cavity, 
constipation,  alimentary  putrefaction,  decrease  of  normal  digestive 
fluids,  intestinal  obstruction,  and  peritonitis.  Certain  drugs,  such  as 
salol,  salophen,  and  creosote,  will  give  nearly  similar  reaction,  while 
urotropin  will  cause  its  disappearance.  These  possible  conditions  must 
all  be  considered. 

As  the  intestinal  contents  pass  through  the  large  intestine  they  be- 
come thickened  through  the  absorption  of  fluids  and  are  at  last  eliminated 
as  feces.  These  comprise  the  remains  of  undigested  material,  excretory 
material  from  the  intestines,  and  many  microorganisms. 

The  quantity  of  feces  depends  upon  the  character  of  the  food,  being 
greater  after  a  vegetable  diet.  The  average  amount  after  a  mixed  diet 
is  about  100  to  150  gm. 

The  reaction  of  the  feces  is  ordinarily  alkaUne,  though  occasionally 
variable.  The  odor  is  chiefly  due  to  skatol,  and  the  color  is  a  light  or 
dark  brown. 

Absorption  from  the  Intestines. — Absorption  chiefly  occurs  in  the 
small  intestine. 


42  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

In  the  stomach  the  greater  part  of  the  protein  is  dissolved  and  much 
of  it  is  converted  into  albumoses  and  peptones. 

In  the  intestine  the  dissolved  products  as  well  as  the  remaining  un- 
dissolved residues  are  attacked  by  the  trypsin  and  are  thereby  split  up 
into  amino-acids.  Erepsin,  a  ferment  from  the  intestinal  wall  prevents 
the  absorption  of  albumoses  and  peptones  by  converting  those  that  es- 
cape the  action  of  trypsin,  into  amino-acids.  The  amino-acids  as  fast 
as  they  are  formed  are  absorbed  and  transported  by  the  blood  and  lymph 
to  all  parts  of  the  body.  Each  tissue  rebuilds  itself  from  the  amino- 
acids.  Those  that  are  not  needed  are  converted  into  urea  and  carbona- 
ceous remainders.  The  latter  are  converted  into  carbohydrates  or 
oxidized  for  the  production  of  heat  and  energy.  The  liver  and  par- 
ticularly the  muscles  form  the  urea. 

Vaughan^  believes  that  the  amino-acids  are  synthetized  into  specific 
proteins  peculiar  to  the  sjjecies.  The  blood  and  lymph  carry  in  solution 
both  proteins  and  protein-split  substances  (amino-acids).  Each  kind 
of  cells  of  the  various  organs  must  split  the  proteins  and  amino-acids  in 
such  a  way  as  to  serve  the  need  of  that  particular  structure,  such  as  the 
liver  cells,  pancreatic  cells,  etc.  The  agencies  which  accomplish  the 
work  are  known  as  ferments  and  there  are  as  many  specific  ferments  as 
there  are  kinds  of  cells. 

Sometimes  small  amounts  of  undigested  or  imperfectly  digested  pro- 
teins are  absorbed  through  the  intestinal  wall.  Foreign  proteins  entering 
the  body  must  be  digested  by  ferments  supplied  by  the  blood  and  tissues. 
This  is  known  as  "parenteral  digestion"  in  contradistinction  to  "enteral 
digestion"  occurring  in  the  alimentary  canal.  With  parenteral  digestion 
poison  from  the  protein  molecule  is  set  free  in  the  blood  and  tissues,  and 
gives  rise  to  symptoms.  Idiosyncrasy  to  certain  foods  may  result  in 
unchanged  proteid  absorption  or  from  partially  proteolized  derivatives 
and  toxic  symptoms  result — in  effect  anaphylaxis  and  sensitization  occur. 

Albuminates  from  animal  food  are  more  completely  converted  than 
those  from  vegetable  food,  on  account  of  the  indigestibility  of  the  cellulose 
and  the  increased  peristalsis  caused  by  the  latter. 

Absorption  of  the  Carbohydrates. — These  are  chiefly  absorbed  as 
monosaccharids  through  the  capillaries  of  the  villi,  enter  the  liver  through 
the  portal  vein,  and  are  retained  as  glycogen  for  use  in  the  animal  economy. 

If  sugar  is  absorbed  in  excess,  it  may  enter  the  general  circulation  and 
be  excreted  by  the  kidneys,  so-called  alimentary  glycosuria.  It  may  also 
cause  diarrhea. 

Carbohydrates,  as  starch,  are  absorbed  without  difliculty. 

Glucose,  levulose,  and  galactose  are  absorbed  as  such,  while  cane- 
sugar  and  maltose  are  first  changed  to  these  products.  Milk-sugar  is 
unchanged  and  absorbed  as  such,  or  undergoes  lactic-acid  fermentation. 

Absorption  of  Fats. — The  process  of  fat  digestion  results  in  the  pro- 
duction of  fatty  acids  and  glycerol,  soaps  also  being  formed  if  the  condi- 
tions under  which  the  alkali  is  contributed  in  the  intestines  are  favorable. 
These  various  products  pass  through  the  alimentary  wall  in  emulsion 
and  are  resynthesized  into  true  fat  at  the  seat  of  their  absorption.  They 
'  Parenteral  Protein  Digestion,  Journal  A.  M.  A.,  .\ug.  i,  19 14. 


PHYSIOLOGY    OF   DIGESTION  43 

enter  the  lacteals  probably  through  the  action  of  the  epitheUal  cells  of 
the  intestinal  wall  and  reach  the  thoracic  duct. 

Mineral  oil  and  petroleum  are  not  absorbed  even  when  introduced 
in  the  finest  emulsion.  The  intestine  rejects  the  paraffin  and  takes  up 
the  fat  and  excludes  undesirable  wool  fats.  The  tissue  fats  maintain  a 
characteristic  similarity  of  composition  in  spite  of  variations  in  the 
texture  and  make  up  of  blood  fat.  Bloor^  has  demonstrated  evidences 
of  various  changes  in  the  fats  during  absorption  which  make  it  probable 
that  the  intestines  are  able  to  radically  modify  their  composition,  the 
tendency  being  toward  the  production  of  a  fat  more  nearly  like  the  typical 
body  fat  of  the  animal  than  the  fat  ingested. 

The  absorptive  power  for  fat  in  the  small  intestine  is  considerable, 
probably  over  300  grams  per  day.  Olive  oil  and  butter  (fats  with  a  low 
melting-point)  are  absorbed  more  quickly  than  mutton  fat,  for  instance 
(fat  with  a  high  melting-point),  and  a  free  fat,  such  as  butter,  is  taken 
up  more  quickly  than  bacon,  which  contains  considerable  connective 
tissue. 

Water,  salts,  some  of  the  secretory  juices,  and  bile  are  readily  absorbed. 

Disease  or  removal  of  the  pancreas  stops  the  absorption  of  fats,  except 
of  milk,  of  which  part  is  absorbed  in  emulsified  form. 

Absorption  in  the  Large  Intestine. — Water,  fluids,  and  salts  are  well 
absorbed,  in  fact,  markedly  absorbed,  as  is  noted  by  the  change  in  the 
character  of  the  intestinal  contents.  Albumin  and  carbohydrates  are 
absorbed  in  considerable  amount  and  fats  in  small  quantities.  Advantage 
is  taken  of  this  fact  for  the  employment  of  nutritive  enemata. 

Intestinal  Peristalsis  (Motor  Function). — The  contents  are  thoroughly 
mixed  by  the  movement  of  the  intestines,  and  the  residuum  left  after 
digestion  is  expelled  through  the  anus. 

There  are  four  types  described; 

First. — Cannon  has  shown  in  animals  that  the  small  intestine  is  much 
more  actively  engaged  in  the  segregation  or  segmentation  of  food  than 
in  its  mere  propulsion.  Actually,  however,  propulsion  is  rapid.  One 
type  of  motility  is  given  over  to  the  segmentation  of  food  in  short 
blocks  in  the  small  intestine,  thus  giving  sufficient  time  for  thorough  diges- 
tion as  well  as  absorption.  During  this  process  the  mucous  membrane, 
with  its  large  absorbing  valvulae  conniventes,  is  thrust  into  the  food 
mass,  thus  exposing  its  maximum  surface  to  absorption. 

Second. — The  second  movement  is  peristaltic,  and  the  intestines  con- 
tract at  a  certain  point  and  then  relax,  and  continue  this  in  successive 
segments  or  blocks  progressively  toward  the  anus,  pushing  the  contents 
forward  {ordinary  peristaltic  movements). 

Third. — Oscillating  movements,  by  which  the  coil  is  moved  to  and  fro 
along  the  mesentery,  with  no  particular  contraction.  The  contents  are 
mixed  up  by  these  movements  and  not  propelled  forward. 

Fourth. — Rotary  movements,  by  which  a  coil  contracts  in  a  circular 
direction  rapidly  along  the  intestines  for  15  or  20  cm.  in  a  violent  manner. 

The  last  is  usually  pathologic  and  occurs  when  there  is  considerable 

^Fat  Absorption,  Jour.  Biol.  Chem.,  19 14,  xvi,  517. 


44  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

gas,  after  indiscretions  in  diet,  or  with  stenosis.  It  is  observed  only 
in  the  small  intestine. 

In  the  duodenum  (descending  and  transverse),  the  chyme  is  propelled 
in  finger-like  masses  (Holzknecht).  The  masses  appear  flocculent  in  the 
jejunum  and  have  a  coagulated  appearance  in  the  ileum.  Propulsion 
is  most  rapid  in  the  jejunum. 

Peristaltic  action  is  much  more  rapid  in  the  small  intestine  than  in 
the  large.  After  ingestion  of  a  small  meal  the  stomach  becomes  empty 
in  about  two  hours,  the  small  intestine  in  the  same  length  of  time;  but 
in  the  large  intestine  it  takes  at  least  twenty  hours  before  the  contents 
are  expelled. 

Nothnagel  has  never  seen  a  physiologic  antiperistalsis  (reversed  peri- 
stalsis) beginning  from  the  anal  direction  upward  toward  the  stomach, 
though  some  describe  an  intermittent  antiperistalsis  occurring  in  the 
ascending  colon.  It  is  said  that  strong  injections  of  salt  water  into  the 
colon  will  produce  this  effect. 

Movements  of  Proximal  Colon. — W.  B.  Cannon,  Amer.  Jour.  Physiol., 
vol.  vi,  p.  253,  has  demonstrated  by  the  Rontgen  rays  that  antiperistaltic 
movements  or  anastalsis,  a  movement  of  waves  backward  toward  the 
cecum,  occur  normally  in  the  cecum,  ascending  and  transverse  colon  of  cats 
thoroughly  churning  and  mixing  the  food,  and  bringing  it  in  more  perfect 
contact  with  the  absorbing  surface  of  the  colon. 

Motor  Functions  of  Large  Intestines.^ — Rieder^  has  brought  evidence 
on  the  basis  of  his  a;-ray  studies  that  anastalsis  occurs  in  the  human 
colon.  Though  it  appears  in  the  main  along  the  cecum,  ascending  and 
proximal  transverse  colon,  it  might  appear  in  any  part  of  the  large 
intestine. 

Haustral  Churning. — Schwarz^  demonstrates  from  his  x-ray  studies 
on  man  that  haustral  changes  occur  constantly.  Rieder  describes  these 
oscillations  of  the  haustra  as  "pendulum  movements." 

Whether  the  predominant  movements  of  the  proximal  colon  are  ex- 
tensive contractions  shifting  the  mass  of  contents  rhythmically  forward 
and  backward,  or  gentle  compressions  of  the  contents  of  the  sacculi,  the 
effect  produced  is  a  thorough  mixing  and  overturning  of  the  material  in 
this  region  and  the  exposure  of  the  semifluid  mass  to  the  absorbing  mucosa. 
The  first  part  of  the  large  intestine  should  be  therefore  regarded  as  a  place 
in  which  digestion  and  absorption  still  continue. 

Movements  of  the  Distal  Colon. — The  distal  colon  may  be  regarded  as 
beginning  in  man  near  the  middle  of  the  transverse  portion  and  contains 
normally,  firm  and  formed  masses  of  waste  material.  The  characteristic 
activity  of  the  intestinal  wall  is  the  onward  moving  wave  or  diastalsis. 
Two  modes  of  advancing  the  contents  have  been  observed.  Holzknecht 
records  by  means  of  the  fluorescent  screen  that  the  contents  of  one  sec- 
tion of  the  colon  is  moved  onward  into  an  empty  distal  section  by  a  sudden 
push,  lasting  a  few  seconds.  The  haustral  segmentation  disappeared 
just  before  the  advancement  began,  but  at  once  reappeared  when  the 
material  settled  in  its  new  position.     This  suggested  that  the  function  of 

^Fortschr.  a.  d.  Geb.  d.  Rontgenstrahletn,  1912,  xviii,  119. 
'Munch,  med.  Woch.,  1911,  Iviii,  1489. 


PHYSIOLOGY    OF   DIGESTION  45 

the  haustra,  as  in  the  proximal  colon,  was  to  increase  intestinal  absorption 
and  not  to  propel  the  feces.  The  second  method  is  reported  by  Fisch- 
land  and  Porges.^  They  saw  a  small  piece,  the  size  of  a  thumb,  separated 
from  the  mass  in  the  transverse  colon,  and  pushed  to  and  around  the 
splenic  flexure  and  thus  down  the  descending  colon.  Several  masses  then 
followed  the  first,  each  new  one  starting  as  the  previous  one  came  to  a 
stop.  Thus  small  or  large  accumulations  are  transmitted  toward  the 
rectum. 

The  interval  between  taking  the  meal  and  the  excretion  of  the  resi- 
due may  vary  between  nine  and  thirty-two  hours,  the  period  depending 
on  the  time  of  eating  and  hour  of  defecation.  The  latter  may  occur 
at  5  p.  M. — nine  hours  after  breakfast  or  if  a  failure  at  this  time,  the 
contents  would  likely  be  retained  for  twenty-four  hours  longer. 

Nervous  Control  of  Peristalsis. — Auerbach's  and  Meissner's  plexuses 
are  probably  the  automatic  centers  for  peristalsis,  but  there  are  central 
agencies.     For  example,  fright  or  excitement  may  cause  diarrhea. 

The  splanchnic  nerve  contains  inhibitory  fibers  for  the  control  of 
intestinal  peristalsis. 

Ehrmann  claims  that  the  longitudinal  muscles  are  stimulated  by  the 
splanchnics  and  inhibited  by  the  vagus,  and  the  circular  muscles  stimulated 
by  the  vagus  and  inhibited  by  the  splanchnics. 

The  chyme  acts  as  the  normal  stimulus  to  peristalsis  through  the 
nerves.  Toxic  material  that  has  been  ingested  or  developed  in  the  in- 
testinal canal,  indigestible  food,  organic  acids  from  excessive  fermenta- 
tion, and  too  hot  or  too  cold  drinks,  may  overstimulate  the  peristaltic 
action  and  be  the  cause  of  diarrhea. 

^ Munch,  med.  Woch.,  191 1,  Iviii,  2064. 


CHAPTER  III 
INTERROGATION  OF  THE  PATIENT  (HISTORY) 

In  every  case  suffering  from  symptome  pointing  to  the  gastro-intestinal 
tract,  before  the  physical  examination  is  undertaken  the  patient  should 
be  carefully  interrogated  as  to  his  general  history  and  the  past  and  present 
symptoms. 

I  shall  briefly  indicate  the  form  of  taking  and  preserving  the  history 
of  such  cases: 

Date Diagnosis No.  of  patient 

Name Nativity 

Age .- .  i Occupation 

Sex. Cause  of  death  of  parents 


Family  and  Personal  History 

Tuberculosis:  Rheumatism- 

Syphilis:  Malaria: 

Diphtheria:  Influenza: 

Scarlatina:  Nephritis: 

Measles:  Heart  disease: 

Typhoid:  Disease  of  liver: 

Gout:  Cancer: 

Habits 

Tea — cups:  _  Sexual  excess: 

Coffee — cups:  Mastication: 

Tobacco:  Character  of  food: 

Alcohol: 

Past  History  of  Present  Complaint 
Began: 
Duration: 

Onset — 

Sudden: 

Gradual: 
Probable  cause: 
Symptoms — 

Progressed : 

Same  in  character: 

Changed  in  character: 

Loss  of  flesh — 
Present: 
Increasing: 
Absent: 

Bowels — 

Constipation:  Mucus: 

Diarrhea:  Blood: 

Alternating:  Odor: 

Regular: 

46 


INTERROGATION    OF    THE   PATIENT  47 

Present  Condition  and  History 


Headache — 

Character: 

Location: 

Time  of: 

Vertigo — 

Nervousness: 

Drowsiness: 

Sleeplessness: 

Appetite — 

Good: 

Bulimia  (canine  hung< 

Anorexia  (loss): 

Polyphagia: 

Time: 

Akoria: 

Parorexia  (perversion): 

Thirst: 

Taste— 

Normal : 

Sour: 

Bitter: 

Sticky: 

Time: 

Deglutition: 

Dysphagia — 

With  solids: 

With  liquids: 

Abnormal  sensations — 

Bloating: 

Pressure: 

Fulness: 

Weight: 

Time: 

Belching — 

Quantity: 

On  empty  stomach: 

Time  of: 

Odor: 

On  full  stomach: 

Regurgitation — 

Water-brash: 

Sour: 

Time: 

Rumination: 

Pyrosis  (heart-burn) — 

Time: 

Duration: 

Pains — 

Location: 

Circumscribed 

Cardialgia: 

Diffuse: 

Gastralgia: 

Radiating: 

Character: 

Sudden : 

Time  of  appearance: 

Gradual: 

Duration: 

Relieved  by  pressure: 

Affected  by  position: 

Increased  by  pressure; 

Affected  by  food  or  drink: 

Local  tenderness — 

Position: 

Rigidity 

Nausea — 

• 

Time: 

Affected  by  food: 

48 


DISEASES    OF    THE    STOMACH   AND    INTESTINES 


Vomiting — 

Time: 

Frequency: 

Quantity: 

Character  of: 

Odor: 

Taste: 
Stools — 

Regular: 

Constipation: 

Diarrhea: 

Alternating  constipation 
and  diarrhea: 

Number  of  movements: 

General  health  and  strength — 
Loss  of  weight: 


Blood  and  its  character: 

Bile: 

Mucus: 

Easy: 

Difficult: 

Relief  of  pain  by: 

Time  of  appearance: 

Undigested  food: 

Mucus: 

Blood: 

General  character: 

Bile: 

Tenesmus: 


Symptoms  Referable  to  Circulatory  System. 

Symptoms  Referable  to  Nervous  System 

Chief  Complaint 

After  the  physical  examination  has  been  made,  the  results  should 
be  incorporated  with  the  history,  as  should  also  the  data  secured  from 
examination  of  the  gastric  contents,  urine  and  stool. 

General  Physical  Examination  Comprises — 

Forehead  and  Face:  Neck — as  to  thyroid  and  glands: 

Tongue:  Uvula:  Tonsils:  Pharynx: 

Teeth:  Esophagus,  if  history  points  to  the  same: 

Eyes — as  to  difficulty  in  reading  or  headache  therefrom;  exophthalmos. 

Nose — as  to  nasal  discharge  and  patency. 

Ears — as  to  deafness. 

Heart:  Blood  pressure: 

Lungs: 

Liver: 

Stomach — 
Position : 
Normal  ■. 
Dilated: 
Gastroptosis: 

Spleen: 

Kidneys — 
Position: 
Urine: 

Intestines — 
Position : 
Tender  points: 
Thickening: 

Rectum — 

Local  examination: 

Examination  of  stool,  including  microscopy  and  fermentation  test. 

Nervous  system: 
Weight  of  patient: 
Examination  of  genital  organs: 


Tenderness: 
Motor  function: 
Tympanites: 
Gastric  analysis: 
Tumor* 


Tympanites: 
Borborygmi: 


CHAPTER  IV 
GENERAL  METHODS  OF  PHYSICAL  EXAMINATION 

As  patients  who  complain  of  digestive  disturbances  may  suffer  from 
disease  of  other  organs  which  may  be  the  cause  of  the  symptoms,  a  thor- 
ough physical  examination  should  be  made  in  every  case.  This  should 
literally  be  carried  out  from  the  top  of  the  head  to  the  soles  of  the  feet; 
in  view  of  the  numerous  conditions  which  may  have  in  association  symp- 
toms pointing  to  the  gastro-intestinal  tract.  It  should  include  the  scalp, 
forehead,  eyes,  face,  nose,  mouth,  ears,  neck,  thorax,  abdomen,  genito- 
urinary organs,  rectum,  the  gait,  patellar  reflexes,  etc. 

There  should  be  a  careful  examination  of  the  heart  and  lungs.  On 
examination  of  the  chest,  it  should  be  noted  as  to  whether  the  patient 
has  the  lon^  narrow  chest  of  a  gastroptotic,  whether  there  are  beaded  ribs, 
a  floating  tenth  rib  and  whether  there  are  dorsal  pain  and  tenderness  to 
the  left  of  the  spine  near  the  eighth  to  tenth  ribs  suggestive  of  gastric 
ulcer  or  to  the  right  suggestive  of  gall-bladder  disturbance.  The  character 
and  rapidity  of  the  pulse,  blood  pressure,  and  respiration  should  be  noted, 
and  a  specimen  of  urine  requested  for  analysis  and  stool  for  general  ex- 
amination. 

In  all  acutely  commencing  processes  pointing  to  the  digestive  tract,  the 
temperature  should  be  taken.  Gastric  analysis  and  stool  examination  are 
important. 

GENERAL  INSPECTION 

The  general  appearance  of  the  patient  may  afford  valuable  informa- 
tion. With  cancer  there  is  often  the  sallow  and  emaciated  appearance 
(cachexia)  with  anemia;  with  gastric  neurosis  the  patient  may  often  appear 
rosy  and  well  nourished;  while  with  ulcer  there  is  frequently  marked 
anemia  and  the  face  may  have  the  appearance  of  suffering.  Protrusion 
of  the  eyeballs,  with  inability  of  complete  closure  of  the  lids,  taken  in 
connection  with  tachycardia,  are  suggestive  of  Graves'  disease,  even 
though  no  thyroid  enlargement  be  present.  Von  Graefe's  sign  and  tremor 
of  the  lids  should  all  be  tested  for.  Determination  of  the  Argyll-Robert- 
son pupil  would  be  of  diagnostic  value.  The  skin  should  be  inspected 
for  eruptions  and  the  exanthemata. 

Oral  Cavity. — This  should  be  carefully  inspected.  Defective  and 
carious  teeth  or  inflammation,  pyorrhea  alveolaris,  or  abscess  of  the  gums 
may  give  rise  to  gastric  disorders.  Disease  of  the  posterior  nares  or 
middle  ear,  with  resulting  discharges  passing  into  the  pharynx,  may  be 
factors. 

The  tongue  was  formerly  regarded  as  a  mirror  of  the  stomach,  but  it 
can  hardly  be  so  considered,  as  there  are  some  gastric  affections  in  which 
the  appearance  of  the  tongue  is  normal;  while  in  smokers,  for  example, 

4  49 


5° 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


the  tongue  may  be  coated  and  yet  no  gastro-intestinal  disturbance  be 
present.  A  thick  gray  or  grayish-yellow,  moist,  coated  tongue  showing 
indentations  is  suggestive  of  chronic  gastritis;  while  with  ulcer  it  may  be 
dry  and  red,  with  a  white  median  stripe,  or  smooth  and  moist  or  slightly 
furred. 

The  condition  of  the  mouth,  smoking,  drinking,  and  the  teeth,  have 
a  decided  bearing  on  its  appearance.  This  is  also  true  in  reference  to 
the  odor  of  the  breath,  I  hardly  deem  the  tongue  diagnostic  in  diseases 
of  the  gastro-intestinal  tract,  except  in  association  with  other  symptoms. 

With  the  typhoid  state,  we  have  the  narrow  tongue,  with  the  deep 
median  fissure,  thickly  furred,  the  tip  and  edges  being  red  and  denuded, 
or  the  dry,  brown  fissured,  and  tremulous  tongue;  while  with  scarlet  fever 
and  in  some  other  acute  specific  infections  there  is  the  so-called  strawberry 
or  raspberry  tongue,  with  bright  red  projecting  papillae. 


Fig.   15. — Kemp's  improved  flexible  esophageal  bougie  with  inch  markings;  stylet; 

perforated  olives. 


The  uvula  is  sometimes  elongated  and  may  cause  reflex  digestive 
disturbances.  In  the  pharynx  and  tonsils  there  may  be  inflammatory 
conditions  of  an  acute  or  chronic  type  which  influence  the  case. 

Inspection  of  the  neck  is  important.  Enlarged  thyroid  with  tachy- 
cardia is  diagnostic  of  Graves'  disease,  and  a  swelling  to  the  left  of  the 
larynx,  which  increases  in  size  after  the  ingestion  of  food,  is  suggestive  of  a 
diverticulum  of  the  esophagus.  Enlargement  of  the  cervical  glands  refer- 
able to  syphilis,  tuberculosis,  leukemia,  inflamed  teeth,  or  head  lice, 
etc.,  would  influence  the  diagnosis. 

Examination  of  the  Esophagus  and  Esophageal  Diseases. — The 
cardinal  symptom  of  esophageal  disease  is  dysphagia,  with  or  without 
regurgitation.  The  object  of  examination  is  to  determine  whether  a 
stricture  or  a  diverticulum  is  present. 

Palpation  of  the  esophagus  is  possible  in  the  neck,  usually  on  the  left 
side  behind  the  trachea.     A  tumor  found  here  may  be  a  diverticulum 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION  5I 

distended  with  food  or  fluid.  It  is  sometimes  possible  to  empty  it  by  the 
exertion  of  pressure.  After  the  administration  of  considerable  water,  on 
rising  a  splashing  sound  can  often  be  determined  by  grasping  the  larynx 
and  shaking  the  patient's  neck.  Respiration  and  swallowing  should  be 
avoided  during  the  test. 

A  brawny  swelling,  in  some  cases  with  subcutaneous  emphysema, 
may  result  from  perforation  or  rupture  of  the  esophagus,  with  inflamma- 
tion, which  proceeds  to  suppuration.  An  abscess  in  this  locality  may  be 
due  to  caries  of  the  vertebrae. 

Auscultation  of  the  esophagus  is  often  of  service.  Place  the  stetho- 
scope posteriorly  to  the  left  of  the  spine,  at  the  level  of  the  sixth  dorsal 
vertebra  or  at  the  tip  of  the  ensiform  and  at  a  signal  let  the  patient  swallow 
a  mouthful  of  water.  At  the  instant  of  swallowing  the  deglutitory  sound 
is  heard,  followed  in  six  or  seven  seconds  by  the  esophageal  bruit,  which 
resembles  the  sound  one  hears  when  swallowing  saliva.  Three  to  five 
seconds  later  there  is  a  second  sound,  caused  by  the  fluid  entering  the 
stomach  or  by  regurgitation  of  air.  If  the  first  sound  is  delayed  longer 
than  seven  seconds,  or  replaced  by  a  splashing  or  gurgling  noise,  or  if  the 
second  sound  is  delayed  longer  than  five  to  twelve  seconds,  partial  stenosis 
may  be  suspected.  If  both  sounds  are  absent,  there  is  probably  nearly 
complete  or  complete  stenosis. 

Gurgling  sounds  lasting  several  minutes  and  heard  along  the  left 
side  of  the  spine  are  probably  due  to  contractions  in  a  diverticulum, 
or  in  the  dilated  portion  of  the  canal  above  a  stricture. 

Instrumental  examination  of  the  esophagus  is  made  by  flexible  stom- 
ach-tubes of  various  sizes — the  safest  method — or  by  flexible  solid  bougies 
or  sounds.  There  is  an  excellent  flexible  bougie  with  small  spiral  wire 
tube  stem  covered  with  rubber  (Lerche).  Olives  of  various  size  can  be 
attached.  Einhorn's  divisible  bougie  is  a  good  instrument,  though  the 
whalebone  handle  is  slightly  stiff.  It  should  not  be  employed  by  a 
novice.  Callmann's  and  Schreiber's  sounds  are  advocated  by  Willy 
Meyer.  With  Schreiber's  instrument  the  deflated  bulb  is  passed  into 
the  stomach  and  is  then  inflated  with  water.  It  i^  then  sfowly  pulled 
upward.  It  moves  readily  in  a  normal  esophagus,  but  slight  narrowing 
or  a  diseased  area  arrest  its  jjassage.  Schreiber  claims  80  to  90  per  cent, 
cases  of  stenosis  to  be  malignant.  The  writer  invariably  examines  the 
pharynx  and  postlingual  region  with  the  finger,  before  attempting  to  pass 
a  stiJJ  instrument,  as  he  has  found  on  several  occasions  adenoids  or  a  pro- 
jecting cervical  vertebra  (from  curvature)  to  interfere  with  its  passage. 

I  have  recently  devised  an  improved  flexible  esophageal  bougie^  with 
which  early  stenosis  can  be  more  readily  detected  through  increased 
delicacy  of  touch  with  a  flexible  instrument  (see  Fig.  15).  It  is  per- 
fectly safe  and  can  be  passed  with  the  head  in  the  natural  position  {i.e., 
without  extension).  There  are  three  stylets  of  varying  stiffness  which  can 
be  inserted  after  the  instrument  has  entered  the  esophagus.  The  stem 
is  small,  only  11  French,  and  has  markings  at  inch  intervals.  There  are 
several  olives  of  different  sizes.     These  are  perforated  so  that  they  can 

^Improved  Flexible  Esophageal  Bougie,  Medical  Record,  Feb.  12,  1916. 


52 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


be  threaded  on  a  silk  guide.  This  instrument  is  simple,  safe  and 
practical  and  can  be  used  with  children. 

Before  the  passage  of  an  esophageal  instrument,  preliminary  spray- 
ing of  the  pharynx  with  4  per  cent,  cocaine  or  5  per  cent,  eucain  may 
be  required.  The  administration  half  an  hour  previously  of  tincture 
belladonna,  gtts.  10,  or  Hoo~/^o  atropine  is  advisable  if  there  is  much 
spasm.  Olive  oil,  5ii-5ss,  ingested  just  before  introduction  of  the 
instrument  aids  its  passage. 

A  practical  method  of  differential  diagnosis  between  stenosis  and 
diverticulum  of  the  esophagus  has  been  devised  by  H.  S.  Plummer^  and 
successfully  employed  by  C.  H.  Mayo.    The  patient  is  directed  at  bed- 


Fig.  16. — Sound  pocketed  in  a  di- 
verticulum. Esophageal  probe  bulb 
threaded  on  a  swallowed  thread  passed 
into  diverticulum  (Plummer). 


Fig.  17. — Traction  on  the  thread 
lifting  the  sound  out  of  the  diverticu- 
lum. Probe  bulb  elevated  by  tighten- 
ing the  thread,  showing  depth  of  sac 
(Plummer). 


time  to  swallow  3  yards  of  buttonhole  silk  twist  with  the  assistance 
of  drinking  water,  and  the  next  morning  to  swallow  three  more  yards  of 
the  continuous  thread;  if  there  is  an  opening  through  the  stricture  or 
diverticulum,  the  thread  will  be  washed  into  the  stomach,  and  from 
there  into  the  bowel,  a  sufficient  distance  to  stand  traction  without  being 
readily  withdrawn.  A  whalebone  stem  with  several  sizes  of  olive  tips  is 
employed  for  the  examination.  There  is  an  opening  at  the  side  of  each 
tip,  the  channel  emerging  at  its  apex.  The  thread  which  is  employed  as 
a  guide  passes  through  the  tip  of  the  olive  and  out  at  its  side.     The 

^  Trans.  Sect.  Surgery,  Amer.  Med.  Assoc,  Sixty-first  Session,  St.  Louis,  June, 
1910;  also  Jour,  Amer.  Med.  Assoc,  February  25,  191 1. 


GENERAL   METHODS    OF   PHYSICAL   EXAMINATION 


53 


instrument  is  passed  down  the  esophagus  on  the  thread,  which  is  held 
loosely  until  an  obstruction  is  encountered.  If  this  is  due  to  a  stricture, 
the  tip  will  not  change  Us  level  when  the  thread  is  tightened;  but  if  there 
is  a  diverticulum,  the  probe  will  be  elevated  to  the  level  of  the  opening 
into  the  lower  esophagus  (Figs.  i6  and  17).  This  proves  at  once  the 
existence  of  a  pocket  and  also  its  depth,  by  the  amount  of  elevation  of 
the  probe  on  tightening  the  thread.  By  means  of  the  thread  as  a  guide 
it  is  possible  to  pass  through  apparently  nearly  impermeable  strictures 
with  a  small  olive  and  gradually  to  dilate  them.  Only  sufficient  force  to 
detect  an  obstruction  and  readily  to  pass  through  it  with  olive  bougies 
of  smaller  size  is  permissible  with  an  unguided  sound.  With  the  silk 
thread  as  a  guide,  sufficient  force  may  be  used  short  of  carrying  the  thread 
out  of  its  course  and  through  the  esophageal  wall.     If  sufl&cient  ob- 


/ 

i 

1/ 

i 

^ 

i 

5^1 

L..  -._  / 

m 

Fig.  18. — Various  forms  of  esophageal 
sounds  (Plummer). 


Fig.  19. — Piano-wire  guide  and  carrier 
(Plummer). 


struction  is  present  to  make  it  possible  that  the  thread  might  be  carried 
out  of  its  course,  a  piano  wire  (Fig.  19)  should  then  be  passed  on  the 
thread,  and  then  the  olive  passed  on  the  wire.  This  renders,  in  some 
cases,  the  sound  more  easily  introduced.  When  passing  the  olive  over 
the  wire,  tension  on  the  thread  should  be  maintained  to  avoid  any  possi- 
bility of  the  tip  of  the  wire  injuring  the  esophagus  or  stomach  wall.  In 
Fig.  19  and  Fig.  iS,  d  are  shown  the  distal  portion  of  the  piano  wire  guide 
and  carrier  for  working  the  wire  through  a  tortuous  cicatricial  stenosis 
on  a  thread.  Various  sizes  of  piano  wire  may  be  used  and  its  flexibility 
may  be  varied  by  the  amount  of  wire  exposed. 

In  the  treatment  of  cicatricial  stenosis,  the  wire  guide  is  not  often 
necessary  after  the  first  dilatation,  and  the  thread  may  be  dispensed 


54 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


with  as  soon  as  the  smaller  sizes  of  spindles  will  readily  pass.  Plummer 
recommends  further  dilatation  with  a  sound  (Fig.  i8,  a,  b),  consisting 
of  a  series  of  superimposed  spindles  (olives),  the  smallest  one  being  at  the 
bottom  and  gradually  increasing  in  size.  Lerche^  has  devised  a  flexible 
wire  shaft  esophageal  sound,  covered  with  rubber,  on  the  ends  of  which 
olives  of  various  sizes  can  be  screwed.  They  are  perforated  so  that  the 
sounds  can  be  threaded  on  a  guide.  The  writer's  instrument  is  shown 
in  Fig.  15.  ^ 

A  stomach-tube  with  a  perforated  metal  tip  can  be  employed  over  a 
thread  as  a  director,  the  tube  being  stiffened  with  a  whalebone  staff,  in 
order  to  obtain  the  contents  of  a  diverticulum,  or,  as  in  Fig.  20,  a  case  of 
diffuse  dilatation  of  the  esophagus,  to  enter  the  stomach.     By  this  method 

it  is  possible  to  feed  the  patient  while  grad- 
ually dilating  the  stenosis,  and  thus  avoid  in 
some  cases  a  preliminary  gastrostomy. 

In  endeavoring  to  calibrate  a  stricture  in 
the  lower  3  inches  of  the  esophagus,  or  to 
dilate  the  same  by  means  of  a  sound,  one  must 
remember  the  following  anatomic  features: 
the  thoracic  portion  of  the  esophagus  lies 
nearly  in  the  median  line,  but  deviates  to  the 
left  as  it  passes  forward  to  the  opening  in  the 
diaphragm.  In  passing  an  olive  through  the 
lower  3  inches  of  a  normal  esophagus  the  staff 
impinges  on  the  left  anterior  wall  and  the  olive 
is  directed  to  the  cardia  by  the  left  posterior 
wall.  This  last  portion  presents  an  increasing 
degree  of  obstruction  as  it  approaches  a  hori- 
zontal plane  in  cases  of  diffuse  dilatation.  The 
degree  of  obstruction  encountered  depends 
also  on  the  stiffness  of  the  staff,  the  size  of  the 
olive,  and  the  tone  of  the  wall  of  the  esopha- 
gus. A  stiff  staff  (Fig.  21,  A)  would  have  a 
tendency  to  injure  or  penetrate  the  wall,  while 
a  flexible  staff,  B,  would  curve  in  conformation 
to  the  shape  of  the  esophagus  and  would  ap- 
proach the  opening  at  an  angle  with  this  portion 
of  the  esophagus  and  no  harm  result. 

In  some  cases,  however,  of  diffuse  dilatation  of  the  esophagus  from 
cardiospasm  an  unguided  sound  cannot  be  passed  with  safety,  but  a  15 
mm.  olive  will  readily  and  safely  pass,  when  guided  by  the  thread. 

The  flexible  sound  or  a  small  stomach-tube  is  more  readily  passed 
and  with  greater  safety  in  the  case  of  a  carcinomatous  cardia  (Fig.  22). 

Benign  Stricture. — A  benign  stricture  may  be  dilated  every  day,  or 
ever}^  other  day,  or  according  to  indication.  The  tise  of  olive  dilators 
or  soft  tubes,  when  possible,  is  preferable.  Soft-rubber  bags  of  various 
design,  introduced  empty  and  then  inflated,  have  been  advocated.  Metal 
dilators  which  can  be  expanded  by  a  screw  thread  and  wheel,  modeled 
1  Jour.  Amer.  Med.  Assoc,  July  29,  191 1. 


Fig.  20. — Metal-tipped 
stomach-tube  guided  by  a 
thread  (Plummer). 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION 


55 


somewhat  after  urethral  dilators,  have  been  devised,  and  Lerche^  recom- 
mends an  esophageal  dilator,  which  is  used  through  the  esophagoscope 
under  guidance  of  the  eye,  somewhat  like  the  Kollman  dilator. 

Malignant  Stricture. — The  history  and  age  of  the  patient  (40-60 
years),  absence  of  the  Wassermann  reaction,  and  cachexia,  will  usually 
determine  malignancy.  A  palpable  tumor  may  sometimes  be  felt  if  the 
stenosis  is  above  the  sternum  and  also  enlarged  glands  are  present.  In 
such  event  the  author  deprecates  the  attempted  passage  of  an  instru- 
ment through  a  cancerous  stenosis. 

In  the  use  of  the  sound  one  must  remember  that  it  is  6  inches  from 
the  incisors  to  the  commencement  of  the  esophagus  at  the  cricoid  cartilage; 


Fig.  21. — Diagram  of  diffuse  esoph- 
ageal dilatation,  showing  danger  from 
stiff  staff  (A),  together  with  use  of 
flexible  staff  (B)  (Plummer). 


Fig.  22.— Passing  a  sound  through  a 
carcinomatous  cardia  (Plummer). 


9  inches  to  the  crossing  of  the  left  bronchus,  and  16  inches  to  the  cardiac 
orifice  of  the  stomach.  There  is  normally  some  constriction  of  the 
esophagus  at  these  three  points. 

Obstruction  to  the  passage  of  the  tube  may  be  due  to  esophageal 
spasm,  but  by  waiting  this  will  usually  subside.  I  have  found  that 
in  some  of  these  cases  a  large  tube  can  be  passed  more  readily  than  a 
small  one.  I  have  treated  neurasthenics  suffering  from  a  temporary  form 
of  spasmodic  stricture.  The  passage  of  a  large  tube  daily  for  the  purpose 
of  overcoming  the  spasm,  antispasmodics  such  as  belladonna  and  the 
bromides,  and  treatment  of  the  neurasthenia  have  relieved  this  condi- 
tion. If  the  tube  passes  readily  on  one  occasion  and  refuses  to  pass  on 
'Jour.  Amer,  Med.  Assoc,  July  29,  191 1. 


56  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

another,  it  has  probably  slipped  into  a  diverticulum,  or  the  latter  has 
filled  up  and  by  pressure  prevented  the  passage  of  the  instrument. 

If  the  obstruction  is  permanent,  one  must  decide  whether  it  is  due 
to  stricture  (narrowing)  or  external  pressure,  such  as  from  aneurysm, 
tumor,  or  enlarged  glands.  Syphilis,  cancer,  tubercular,  peptic,  and 
rarely  typhoid  ulcers,  and  contraction  following  burns  from  acids  or  alkalis 
are  the  principal  causes  of  stricture.  Congenital  stricture  is  rare  and 
is  usually  found  in  the  upper  part  of  the  gullet. 

If  stricture  be  present,  the  locality,  caliber,  and  permeability  must 
be  determined. 

Locality. — Pass  the  tube  or  olive  to  the  strictured  point,  nip  it  close 
to  the  incisor  teeth,  and  measure  the  distance  from  here  to  the  entering 


Fig.  23. — Diverticulum  of  esophagus,  from  skiagraph  (Plummer). 

tip  of  the  tube  or  olive  after  withdrawal.  My  instrument  has  inch 
markings  which  facilitate  this. 

Caliber. — Sounds  or  olives  of  varying  diameters  will  determine  the 
caliber  by  finding  one  which  will  pass  the  obstruction.  By  the  esophageal 
bruit  and  the  use  of  a  somewhat  rigid  sound  one  can  tell  whether  or  not 
the  obstruction  is  permeable. 

Occasionally  small  portions  of  new  growth  may  be  found  in  the  open- 
ings of  a  fenestrated  tube.     Blood  shows  ulceration  or  erosion. 

Contraindications. — The  tube  should  never  be  passed  if  there  is 
aneurysm  of  the  thoracic  aorta  or  recent  vomiting  of  blood. 

X-ray  Examination. — From  a  pfactical  standpoint,  stenosis  of  the 
esophagus  can  be  readily  diagnosed  by  the  various  methods  of  sound- 
ing, and  a  diverticulum  by  the  symptoms  already  described,  and  by 
Plummer's  thread  method  as  a  guide,  to  which  the  writer  has  already  re- 


GENERAL    METHODS    OF   PHYSICAL   EXAMINATION 


57 


f erred.  Radiography,  however,  is  advised.  Rontgenography  will  disclose 
thoracic  masses  obstructing  the  esophagus  by  outward  pressure  and 
occasionally  an  esophageal  tumor.  An  impacted  foreign  body  can  also 
be  thus  determined.  Other  methods  for  the  determination,  particularly 
of  early  esophageal  stenoses,  have  been  suggested.  Bassler,  for  example, 
first  passes  a  collapsed  bag  on  the  end  of  a  small  tube  into  the  stomach. 
He  then  inflates  the  bag  and  withdraws  it  up  to  the  cardiac  orifice,  thus 
plugging  the  latter.  Barium  or  bismuth  is  then  ingested,  and  fluoros- 
copy, or  preferably  a  radiograph,  will  demonstrate  an  irregularity  in  the 
esophagus  (a  commencing  stricture).  The  bag  is  then  deflated  and 
removed.  Others^  have  the  patient  swallow  a  small,  long,  finger-shaped 
bag  of  gold  beater's  skin  or  animal  membrane — closed  except  at  point 
of  exit  from  the  mouth.     This  is  then  filled  with  barium  or  bismuth 


Fig.   24. — Diverticulum  of  esophagus,  from  skiagraph  (Plummet). 

and  the  esophagus  radiographed.  Subsequently  the  patient  is  placed  in 
Trendelenburg  position  and  the  contents  of  the  bag  evacuated  when  the 
latter  is  also  removed.  The  position,  shape,  size,  and  relations  of  diver- 
ticula and  dilatation  are  also  shown  when  filled  with  barium  mixture. 
Diverticula  are  thus  demonstrated  in  Figs.  23  and  24. 

Large  dilatations  occurring  in  the  upper  third  of  the  esophagus  above 
organic  strictures  usually  have  a  tail-like  portion  of  bismuth  extending 
down  from  the  bottom  of  the  sac,  thus  distinguishing  them  from  diver- 
ticula. When  the  tail  is  absent,  and  there  is  doubt,  Plummer's  thread 
guide  method  will  differentiate  the  two  conditions. 

With  diffuse  dilatation  of  the  esophagus,  following  spasmodic  and 
infrequently  organic  stricture,  at  the  cardia,  the  shadow  is  large  and 
irregularly  spindle  shaped.  Under  the  section  entitled  "Diffuse  Dilata- 
tion of  the  Esophagus  without  Anatomic    Stenosis,"  other  etiological 

^  W.  H.  Stewart,   "Advanced   Rontgen  Technic   in  the  Diagnosis  of  Esophageal 
Lesions,"  "American  Journal  of  Rontgenology,"  October,  1914. 


58 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


factors  besides  cardiospasm  are  shown  to  produce  this  condition.  JVIore- 
over  cardiospasm  may  occur  without  causing  diffuse  dilatation  of  the 
esophagus  or  even  dilatation  at  all. 

Withi  cardiospasm,  the  lower  extremity  of  the  shadow  is  cone-shaped 
and  its  apex  corresponds  to  the  hiatus  esophagi  (Fig.  25).  With  organic 
stricture,  with  diffuse  dilatation,  the  outline  is  irregular  and  terminates 
above  the  hiatus.     In  most  cases  the  dilatation  extends  to  the  upper 


Fig.  25. — Diffuse  dilatation  of  the  esophagus  in  case  of  cardiospasm  (Plummer). 

border  of  the  manubrium  and  is  constricted  at  the  root  of  the  lung.  Dila- 
tation occurring  above  organic  strictures  are,  as  a  rule,  of  limited  extent 
and  irregular  in  outline  in  their  lower  portion. 

Mucilage  of  acacia  is  recommended  as  a  valuable  vehicle  for  the 
bismuth  mixture  and  zoolak  for  barium. 

Other  methods  of  differentiating  a  dilatation  of  the  esophagus  and  a 
diverticulum  have  been  described,^  but  those  to  which  the  author  has 
referred  are  the  most  practical. 

^  Kelen,  New  York  Med.  Jour.,  Feb.  23,  1907. 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION 


59 


The  writer  briefly  suggests  the  following  methods  of  treatment: 

For  benign  stricture  or  cardiospasm  with  dilatation  of  the  esophagus, 
soft-rubber  inflating  bags  and  mechanical  dilators,  opening  their  jaws 
by  manipulating  a  screw  thread  from  above,  have  been  advocated.  The 
use  of  various  sized  olive  dilators,  combined,  when  necessary,  with  the 
thread  guide,  as  devised  by  Plummer,  seems  most  practical. 

Soft  dilators  which  can  be  distended  with  air  or  water  (Plummer's) 
to  which  a  manometer  is  attached,  to  measure  the  pressure  are  of  ser- 
vice, particularly  for  the  purpose  of  diluting  spasmodic  stenosis.  When 
the  patient  begins  to  have  pain,  then  the  pressure  of  the  dilating  fluid 
should  be  diminished. 

In  persistent  spasmodic  strictures,  gastrostomy,  with  rest  to  the 
esophagus  and  feeding  through  the  fistula  temparorily,  will  often  effect 
a  cure.  Dilatation  of  the  spasmodic  stricture  is  carried  out  after  op- 
eration, and  the  gastrostomy  opening  is  closed  later. 

At  times  internal  section  of  the  stricture  can  be  made  by  manipulation 
through  an  esophagoscope,  but  this  is  rather  dangerous;  or,  on  occasions,  a 
preliminary  gastrostomy,  with  the  subsequent  thread-cutting  method  of 
Abbe,  may  be  employed.  Willy  Meyer^  reports  a  successful  case  of  im- 
permeable cardiospasm  treated  by  thoracotomy  and  esophagoplication. 

Syphilitic  cases  require  appropriate  treatment — "606,"  or  neosalvarsan, 
etc. 

Thiosinamin  (0.06  to  0.12)  has  been  recommended  hypodermically 
every  two  to  three  days  as  an  aid  to  the  treatment  of  benign  strictures. 

Liquid  diet  is  indicated  and  lavage  of  the  diverticulum  or  dilated 
esophagus  during  medical  treatment.  In  the  case  of  malignant  stricture, 
radical  operation  may  occasionally  be  possible  if  the  stenosis  is  high  up 
and  there  is  no  great  involvement. 

Preliminary  gastrostomy  is  indicated  in  such  an  event.  Torek  re- 
ports successful  resection  of  one  case  through  the  thorax.  Gastrostomy 
is  indicated  for  the  purpose  of  prolonging  life  in  all  malignant  cases.  For 
the  cure  of  diverticula  operative  procedure  is  usually  required. 

Foreign  Bodies  in  the  Esophagus. — Foreign  bodies  may  be  classified 
as  inorganic  and  organic.  The  former  are  subdivided  into  smooth,  round 
bodies  such  as  coins,  beads,  pebbles,  etc.,  and  into  irregular,  sharp  bodies 
such  as  nails,  pins  and  glass.  Organic  substances  consist  of  vegetable 
substances  which  swell  in  the  presence  of  fluids  such  as  beans,  those  which 
do  not  swell,  and  also  animal  bodies. 

Symptoms. — There  are  primary  symptoms  resulting  from  the  im- 
pacture  of  a  foreign  body  in  the  esophagus.  There  is  first  a  voluntary 
effort  at  expulsion,  and  with  failure  of  this,  a  temporary  spasm  of  the 
glottis,  resulting  in  some  cases  in  severe  inspiratory  dyspnea,  cyanosis, 
slow  heart  action  and  collapse.  The  initial  paroxysm  of  suffocation 
varies  in  severity  and  may  even  result  in  death.  These  symptoms 
are  due  to  irritation  of  the  superior  laryngeal  nerve.  The  initial  symp- 
toms may  entirely  subside  to  be  ultimately  followed  by  secondary  symp- 
toms due  to  the  obstruction  below,  or  the  initial  symptoms  may  be  very 
slight.  Impaction  most  frequently  occurs  at  the  beginning  of  the 
*Jour.  Amer.  Med.  Assoc,  May  20,  ign. 


6o  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

esophagus  opposite  the  sixth  cervical  intervertebral  cartilage,  behind  the 
cricoid;  second  in  the  thoracic  part  opposite  the  fourth  dorsal  vertebra, 
where  the  left  bronchus  crosses,  and  third  at  its  termination  where  it 
passes  through  the  diaphragm.  There  may  be  only  moderate  spasm 
followed  with  slight  diflSculty  in  swallowing.  However,  pain,  dysphagia, 
regurgitation,  nausea,  vomiting,  singultus,  cough,  hoarseness  and  hemor- 
rhage are  symptoms  common  to  impaction  in  any  part  of  the  esophagus. 
The  foreign  body  may  remain  impacted,  causing  only  partial  obstruc- 
tion, for  a  long  period.  Secondary  symptoms  such  as  acute  esophagitis, 
peri-esophagitis,  ulcer,  perforation,  hemorrhage,  death  from  erosion  or 
perforation  of  the  aorta,  pneumothorax,  etc.,  may  result. 

Diagnosis. — The  body  should  be  located  by  the  ac-rays.  When  they 
are  not  available  the  esophagoscope  is  of  service. 

Treatment. — The  object  may  be  removed  by  forceps,  special  coin 
catcher,  etc.,  preferably  with  the  aid  of  direct  vision  through  the  esopha- 
goscope. Occasionally  if  it  is  round  and  smooth  it  can  be  pushed  into 
the  stomach. 

Acute  Esophagitis. — Mechanical,  chemical,  or  thermal  irritation  (too 
hot  liquids)  are  the  chief  causes.  It  may  also  accompany  acute  infectious 
diseases  or  result  from  extension  from  adjacent  tissues. 

Types. — It  may  be  catarrhal,  follicular,  ulcerative,  phlegmonous,  or 
necrotic. 

Symptoms. — With  corrosive  poisons,  inspection  of  the  throat  and 
pharynx  often  makes  the  case  clear,  and  there  may  be  vomiting  of  necrotic 
mucosa  streaked  with  blood.  Pain,  dysphagia,  and  thirst  are  present  in 
most  cases,  with  expectoration  of  mucus  in  the  milder  types.  Pain  is 
increased  on  swallowing  dry  or  hard  food  or  very  hot  or  cold  fluids. 
Instrumentation  is  painful ;  occasionally  perforation  may  take  place  in  the 
phlegmonous  or  necrotic  types. 

Treatment. — Antidotes  and  emollients  are  indicated  in  the  cases  due 
to  poisoning,  and  also  immediate  lavage.  Olive  oil  with  bismuth  in  sus- 
pension is  of  value,  and  hot  or  cold  external  applications.  Small  bits  of 
ice  dissolved  in  the  mouth  may  furnish  temporary  relief.  Rectal  feeding 
may  be  temporarily  indicated.  Rarely  a  hypodermic  of  morphin  or 
codein  may  be  required.  The  occasional  use  of  a  2  per  cent,  cocain  or 
eucain  spray  may  render  swallowing  less  painful. 

Chronic  Esophagitis. — This  type  of  esophagitis  occurs  most  frequently 
in  alcoholics  or  is  secondary  to  cardiac  or  pulmonary  disease  of  long  stand- 
ing. It  may  follow  an  acute  esophagitis  or  be  secondary  to  an  inflam- 
matory condition  occurring  with  carcinoma  of  the  esophagus,  dilatation, 
or  a  diverticulum.     Thrush  may  also  extend  into  the  esophagus. 

Pathology. — There  are  grayish  streaks  of  degenerated  epithelium  on 
the  summit  of  the  longitudinal  folds  and  an  increase  of  mucus.  The 
mucosa  may  be  dusky  red  or  bluish  and  have  a  granular  appearance,  with 
local  areas  of  desquamation  or  ulceration. 

Symptoms. — There  may  be  uneasiness  or  difficulty  in  swallowing  and 
a  feeling  of  distress  behind  the  sternum,  which  persists  after  irritating  food 
or  drink.     The  symptoms  may  be  masked  by  those  of  the  primary  disease. 

Treatment. — The  main  indication  is  removal  or  treatment  of  the  cause. 


GENERAL  METHODS  OF  PHYSICAL  EXAMINATION        6l 

Alcohol,  spiced  foods,  acids,  and  hot  fluids  are  to  be  avoided.  Demulcents 
and  soft  food  are  indicated.  Occasionally,  local  application  of  a  weak 
solution  (i  per  cent,  of  silver  nitrate  or  tannin)  may  be  of  value.  Bismuth 
subnitrate,  30  grains  (0.2),  suspended  in  i  to  2  ounces  of  olive  oil,  three 
times  a  day,  particularly  before  food  is  given,  is  useful  when  there  are 
erosions. 

Ulcers  of  the  Esophagus. — Etiology. — Severe  burns  from  the  ingestion 
of  acids  or  alkalis,  syphilis,  typhoid,  cancer,  and  tuberculosis  may  pro- 
duce local  ulceration  of  the  esophagus.  Decubital  ulcers  may  occur  in 
emaciated  persons  who  have  suffered  from  wasting  disease.  They 
usually  are  found  at  a  level  with  the  cricoid  cartilage,  resulting  from 
pressure,  probably  of  the  esophagus,  between  the  larynx  and  vertebrae 
when  in  the  dorsal  position.  Pressure  ulcers  may  result  from  circulatory 
interference  of  growths  encroaching  on  the  esophagus.  Uremic  ulcers 
occasionally  occur  and  peptic  ulcers  are  probably  the  most  common. 

The  latter  possibly  result  in  part  from  regurgitation  of  the  gastric 
juice.  The  peptic  ulcer  of  the  esophagus  resembles  that  of  the  stomach. 
In  some  cases  it  lies  just  above  the  orifice  of  the  cardia,  while  in  others 
it  begins  in  the  stomach  and  extends  through  the  cardia  into  the  esophagus. 

Symptoms. — In  some  cases  esophageal  ulcer  is  latent  during  life,  while 
in  others  there  are  no  symptoms  until  perforation  takes  place.  Dysphagia 
and  hemorrhage  may  occur.  If  the  ulcer  lie  well  up  in  the  esophagus,  there 
may  be  local  pain  on  swallowing  at  the  site  of  the  ulceration;  while  with 
the  peptic  type  the  pain  lies  behind  the  sternum  or  at  the  level  of  the  ensi- 
form.  It  may  radiate  to  the  back.  The  pain  usually  occurs  on  swallow- 
ing or  immediately  afterward,  and  is  thus  earlier  than  with  gastric 
ulcer. 

Diagnosis. — During  active  hemorrhage  no  instrumentation  should  be 
employed.  About  ten  days  later,  the  gentle  passage  of  soft  stomach- 
tubes  of  various  size  may  enable  one  to  determine  the  sensitive  area  of  the 
ulcer.  Olives  of  various  sizes  with  a  flexible  stem  may  be  cautiously  em- 
ployed for  the  same  purpose.  In  some  cases  one  may  examine  carefully 
with  the  esophagoscope  without  the  mandrin,  with  the  light  turned  on, 
as  in  the  case  of  removal  of  foreign  bodies.  Einhorn  recommends  locating 
the  ulcerated  area  by  the  thread  method.  The  patient  swallows  about  2 
feet  of  No.  15  braided  surgeon's  silk,  the  end  being  tied  about  the  patient's 
ear.  This  is  left  in  situ  for  two  to  three  hours  and  then  withdrawn.  Blood 
will  stain  the  thread  where  it  passes  over  the  ulcerated  surface,  and  its 
distance  from  the  mouth  can  thus  be  located. 

This  method  for  esophageal  ulcer  is  much  more  accurate  than  when 
employed  for  gastric  ulcer,  for  obvious  reasons.  It  is  worthy  of  trial 
in  the  former,  but  the  writer  does  not  believe  it  of  value  for  the  diagnosis 
of  duodenal  or  gastric  ulcer. 

Perforation  of  the  Esophagus. — Intense  thoracic  pain,  dyspnea, 
and  collapse  are  the  salient  symptoms,  Pneumothorax  or  hydropneu- 
mothorax  may  follow.  If  perforation  occur  high  up  in  the  neck,  local 
inflammation  may  result.  Perforation  may  also  take  place  into  the 
mediastinum.  If  perforation  occurs  below  the  diaphragm,  subphrenic 
abscess  or  peritonitis  may  follow. 


62  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Treatment  of  Ulcer. — For  hemorrhage,  morphin,  3-^  to  3^  grain  (0.008- 
0.016),  should  be  given  by  hypodermic  injection.  Adrenalin  chlorid  (i: 
1000),  5  to  10  drops  in  ^i  to  i  ounce  of  water,  is  to  be  administered  by  mouth 
for  the  local  styptic  effect.  Gelatin  solution  or  Tremoliere's  solution, 
as  described  under  Gastric  Ulcer,  should  also  be  given.  A  piece  of  cracked 
ice  may  be  swallowed  and  an  ice-bag  applied  externally. 

Rectal  feeding  should  be  employed  for  a  few  days,  and  subsequently 
liquid  diet  for  several  weeks.  The  patient  should  remain  in  bed.  Bis- 
muth subnitrate  in  30-grain  (0.2)  doses  should  be  begun  on  the  second 
or  third  day  in  i  ounce  of  water  by  mouth,  four  times  daily. 

Tincture  of  belladonna,  10  drops,  four  times  a  day,  in  i  dram  (4.0) 
of  water  can  be  given  for  the  spasmodic  pain.  If  the  ulceration  be 
syphilitic,  as  shown  by  the  Wassermann  reaction,  "606,"  neosalvarsan,  or 
appropriate  antiluetic  treatment  should  be  instituted.  Tubercular  ulcer 
may  receive  local  treatment  through  the  esophagoscope  and  at  times  ulcers 
of  other  types.  A  bougie  should  occasionally  be  cautiously  passed  to 
prevent  stenosis.  If  symptoms  of  the  last  occur,  treatment  should  in  any 
event  be  at  once  begun. 

If  recurrent  hemorrhages  occur  or  stenosis  becomes  progressive,  a 
gastrostomy  is  indicated.  The  stricture  should  be  ultimately  divided. 
If  perforation  occurs,  operation  is  indicated.  Its  character  depends  on 
the  location  of  the  perforation. 

Gastrostomy  is  also  indicated  in  connection  with  the  emergency  opera- 
tion, in  order  to  give  rest  to  the  esophagus  and  thus  enable  one  to  feed  the 
patient. 

Syphilitic  Paralysis  of  the  Esophagus. — R.  Saundby^  reports  a  case  of 
syphilitic  paralysis  of  the  esophagus.  The  patient  had  difficulty  in  swal- 
lowing, with  regurgitation  of  fluids.  There  was  no  obstruction  to  the 
passage  of  a  sound.  For  eight  days  it  was  necessary  to  feed  him  by  a  tube. 
Under  antisyphilitic  treatment  he  made  a  rapid  recovery. 

Stricture  of  the  Esophagus. — The  method  of  determination  of  stricture 
of  the  esophagus,  malignant,  benign,  and  that  due  to  cardiospasm  of 
persistent  type,  with  resulting  fusiform  dilatation  of  the  esophagus, 
has  previously  been  described.  Lerche^  describes  three  cases  of  membran- 
ous stricture  of  unknown  origin. 

Diffuse  Dilatation  of  the  Esophagus  without  Anatomic  Stenosis 
(Cardiospasm). — Diffuse  dilatation  of  the  esophagus  without  anatomic 
stenosis,  occurs  with  cardiospasm,  but  as  it  is  also  due  to  other  causes 
Plummer^  justly  holds  that  a  change  in  nomenclature  would  be  advisable. 
Some  term  this  condition  an  idiopathic  dilatation. 

Etiology. — The  following  have  been  considered  factors  in  the  produc- 
tion of  this  condition:  primary  cardiospasm;  primary  atony  of  the  muscula- 
ture of  the  esophagus;  simultaneous  development  of  paralysis  of  the  cir- 
cular muscles  of  the  esophagus  through  degeneration  of  the  vagi  with 
cardiospasm;  congenital;  primary  esophagi tis;  kinking  of  the  hiatus 
esophagi,  gross  lesions  of  the  esophagus  or  stomach;  congenital  or  acquired 
asthenia,  and  vagotonia. 

^  Brit.  Med.  Jour.,  Jan.  31,  1914. 

2  Journal  A.  M.  A.,  April,  iq,  1913. 

'  Journal  A.  M.  A.,  Aug.  15,  1908,  and  June  29,  191 2. 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION  63 

Cardiospasm  may  occur  with  sight  dilatation  of  the  esophagus  above 
the  point  of  spasm  or  with  no  dilatation  at  all.  The  writer  has  referred 
to  cardiospasm  as  seen  occasionally  in  neurasthenics. 

Symptoms. — These  patients  complain  of  distress  or  difficulty  in  swal- 
lowing, choking,  dragging  under  the  sternum  and  discomfort  or  pain  in 
the  epigastrium.  Regurgitation,  often  described  by  the  patient  as 
vomiting,  frequently  occurs  early  in  the  disease  and  within  a  few  minutes 
to  an  hour,  the  food  is  partly  or  completely  expelled.  In  some  cases  food 
taken  at  a  previous  meal  is  regurgitated.  The  third  stage  is  characterized 
by  irregular  regurgitation,  with  the  discharge  of  food  while  lying  down, 
with  the  patient  being  occasionally  wakened  by  food  in  the  mouth  or  nose. 
There  are  loss  of  flesh  and  strength ;  aspiration  and  tests  show  that  the  food 
in  these  extreme  cases  comes  from  the  esophagus.  In  mild  cases  we  may 
secure  the  food  both  from  above  the  stenotic  area  and  from  the  stomach 
and  compare  them  analytically.  Sounds,- bougies  and  the  x-rays  confirm 
the  diagnosis.  The  esophagoscope  is  sometimes  indicated  for  exploration. 
I  rarely  find  it  necessary. 

Treatment. — Plummer's  hydrostatic  dilator  under  pressure  of  675 
mm.  of  Hg.  as  an  average,  has  benefited  many  cases.  The  degree  of  pain 
has  been  considered  a  measure  for  the  dilatation — and  when  such  is 
complained  of,  dilatation  should  be  stopped.  Operation  may  at  times  be 
required  such  as  that  of  ^Mikulicz.  Temporary  gastrostomy  to  rest  the 
esophagus,  may  be  indicated,  and  Willy  Meyer  reports  a  successful 
thoracotomy  and  esophagoplication.  Atropine  gr.  }4oo~Ho  t.i.d.,  bro- 
mides, valerian  and  tonics  are  particularly  indicated  when  vagotonia  is 
the  cause.  Liquid  diet  of  high  caloric  valu  with  cream  butter,  etc.,  is 
indicated,  also  esophageal  lavage. 

Carcinoma  of  the  Esophagus. — Cancer  may  occur  in  any  part  of  the 
esophagus,  with  resulting  stenosis  and  infiltration  of  the  neighboring 
structures. 

In  the  English-speaking  countries,  statistics  show  that  cancer  of  the 
esophagus  is  only  slightly  less  frequent  than  carcinoma  of  the  stomach. 
The  disease  is  most  frequent  in  the  male  and  usually  occurs  between  the 
ages  of  forty  and  sixty  years. 

The  squamous-celled  epithelioma  is  the  most  common,  or  the  adeno- 
carcinoma. Occasionally  the  growth  is  of  the  soft,  fungating,  cauliflower 
type.  Stenosis  results,  with  dilatation  of  the  esophagus  above  the  point  of 
stricture. 

Symptoms. — In  a  patient  over  forty  years  of  age,  in  whom  there  is  no 
history  or  any  cause  that  might  produce  a  cicatricial  stricture  of  benign 
type,  where  dysphagia  (difficulty  in  swallowing  food)  gradually  develops, 
when  stenosis  is  determined  by  examination  and  the  patient  is  rapidly 
losing  weight  and  strength,  carcinoma  is  properly  the  diagnosis.  Regur- 
gitation of  food  is  present,  and  the  higher  the  obstruction,  the  sooner  it 
occurs.  The  food  regurgitated  or  aspirated  is  alkaline  and  contains  no 
gastric  secretion.  Blood  (visible  or  occult)  and  also  pus  are  present  later 
when  ulceration  has  occurred.  One  of  the  recurrent  laryngeal  nerves  may 
become  involved  and  there  may  be  dyspnea  and  a  hoarse  voice.  If  the 
sympathetic  system  is  affected,  there  may  be  contraction  of  the  pupil  on 


64  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

that  side,  with  ptosis  and  sluggish  reaction  to  light.  There  is  a  feeling  of 
pressure  and  sometimes  severe  pains  are  present  near  the  seat  of  the 
growth  or  radiating  into  the  shoulders  and  back.  Cachexia  and  marked 
anemia  develop.  Occult  blood  may  be  found  in  the  feces.  The  cervical 
and  supraclavicular  glands  are  often  palpable  later  in  the  course  of  the 
disease.  The  growth,  with  enlarged  glands,  if  it  be  in  the  neck  above  the 
level  of  the  sternum,  is  palpable  quite  early. 

The  growth  usually  extends  into  the  surrounding  tissues,  involving 
eventually  the  blood-vessels,  nerves,  pleura,  lungs,  diaphragm,  peri- 
cardium, mediastinum,  and  glands. 

The  method  of  examination  for  all  types  of  stenosis  has  already  been 
described.  Syphilis  should  be  excluded  by  the  Wassermann  and  Noguchi 
tests. 

Early  Diagnosis. — When  a  patient  complains  of  difficulty  in  swallow- 
ing arousing  in  the  physician's  mind  the  suspicion  of  a  commencing  stenosis 
of  the  esophagus,  local  examination  should  be  immediate.  With  a  normal 
esophagus,  the  impression  to  the  fingers  guarding  the  sound  is  that  of  a 
smooth  elastic  surface  while  with  a  change  in  the  tissue  or  a  slight  narrowing 
from  benign  or  malignant  cause,  an  uneven  surface  is  felt.  The  author's 
flexible  esophageal  bougie  is  particularly  adapted  for  detecting  such. 
Radiography  should  be  employed  in  every  case. 

Bassler's^  method  by  plugging  the  cardia  and  injecting  bismuth  and 
then  radiographing,  and  the  use  of  goldbeater's  skin  and  animal  mem- 
brane bags  have  been  previously  described. 

Esophagoscopy  has  also  been  employed  to  detect  a  commencing  growth, 
and  a  section  of  the  latter  has  been  removed  for  examination.  There  is 
the  possible  danger  of  inflammation  and  perforation.  Exploratory 
thoracotomy  has  also  been  suggested. 

Treatment. — Gastrostomy  is  indicated  and  later  complete  excision 
of  the  growth,  if  such  be  possible.  Gastrostomy  in  any  event  allows 
feeding  the  patient  through  the  fistula  and  thus  prolongs  life. 

Franz  Torek  has  performed  intrathoracic  resection  successfully  in  one 
patient  and  there  has  been  one  other  successful  case.  Three  years  and 
two  months  have  elapsed  and  Torek  informs  me  the  patient  is  still  in 
perfect  health.  Willy  Meyer^  describes  various  methods  of  extrathoracic 
and  intrathoracic  esophagoplasty  in  connection  with  resection  of  the 
thoracic  portion  of  the  esophagus. 

If  consent  cannot  be  obtained  for  operation,  lavage  of  the  esophagus 
above  the  stricture,  liquid  diet,  cocain  (2  per  cent,  spray),  or  eucain  (3 
per  cent,  spray)  before  eating,  and  hypodermics  of  morphin,  J^  to  H  grain 
(0.008-0.016),  to  relieve  pain,  are  indicated.  The  ingestion  of  olive  oil, 
}i  to  I  ounce  before  each  feeding,  aids  the  passage  of  food  through  the 
stricture,  just  as  it  is  of  value  in  pyloric  stenosis  for  the  same  purpose. 
Local  treatment  with  radium  and  cautious  dilatation  may  be  tried. 

The  writer  considers  the  condition  usually  fatal  and  palliative  operation 
(gastrostomy)  only  justifiable  in  advanced  cases.     In  early  cases  there 

^  Journal  A.  M.  A.,  April  26,  1913. 

*  Journal  A.  M.  A.,  Jan.  10,  1914;  also  Transactions  Surgical  Section,  A.  M.  A., 
June,  1913;  Surgery,  Gynecology  and  Obstetrics,  Dec,  1912. 


GENERAL   METHODS   OF   PHYSICAL   EXAMINATION 


6S 


appears  to  be  some  hope  of  success  by  a  more  radical  procedure.  Torek's 
result  is  certainly  brilliant.  I  refer  my  readers  for  operative  treatment 
to  Torek's  article  in  the  Annals  of  Surgery,  April,  191 5. 

Benign  Growths  of  the  Esophagus. — These  are  rare  and  usually  of 
small  size,  such  as  fibroma,  papilloma,  myoma,  fibromyoma,  and  lipoma. 
They  may  be  single  or  multiple,  pedunculated  or  sessile.  The  symptoms 
are  those  of  a  mild  stenosis.  The  esophagoscope  will  determine  their 
presence  and  in  some  cases  they  can  be  removed  through  it  by  a  snare. 

Examination  of  the  Abdomen. — The  special  methods  of  physical  ex- 
amination of  the  stomach  and  intestines  are  described  in  the  parts  of 
this  volume  devoted  to  these  subjects.  It  seems  advisable  to  refer  to  the 
general  methods  of  examination  of  the  abdomen  and  the  other  viscera. 

Anatomic  Landmarks. — The  ensiform  appendix  and  down-curved 
arches  of  the  ribs  constitute  the  upper  bony  landmarks.     The  iliac  crests. 


Fig.  26. — Topographic  areas  of  the  abdomen. 


anterior  superior  spines  of  the  ilia,  and  the  symphysis  pubis  in  the  median 
line  are  the  lateral  and  lower  boundaries. 

The  linea  alba  lies  between  the  recti  muscles  in  the  median  line,  runs 
from  the  ensiform  appendix  to  the  pubic  symphysis,  and  is  visible  as  a 
groove  above  the  umbilicus. 

The  umbilicus  is  somewhat  variable  in  its  position,  though  usually 
lying  about  2  inches  above  the  bispinal  line  drawn  transversely  between 
the  anterior  superior  spines  of  the  ilia  or  about  the  level  of  the  crests 
of  the  ilia.  The  recti  muscles  lie  on  each  side  of  the  linea  alba  and  are 
bounded  externally  by  the  lineae  semilunares,  which  run  with  an  outward 
curve  from  the  lowest  part  of  the  seventh  rib  to  the  pubic  spines.  These 
lines  lie  on  each  side  about  3  inches  from  the  umbilicus. 

Topographic  Areas. — In  order  to  describe  the  situation  of  organs  or 
5 


66  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

lesions,  the  surface  of  the  abdomen  is  divided  into  regions,  of  which  the 
method  depicted  in  Fig.  26  is  in  general  use. 

There  are  nine  regions  divided  off  by  four  lines,  two  horizontal  and 
two  vertical.  The  horizontal  lines  are  the  infracostal  or  subcostal,  drawn 
transversely  at  the  level  of  the  inferior  borders  of  the  tenth  ribs,  and  the 
bispinal  line,  connecting  the  anterior-superior  spines  of  the  ilia.  The 
vertical  lines  pass  through  the  center  of  Poupart's  ligament  on  each 
side  and  are  downward  prolongations  of  the  mammillary  lines  of  the  thorax. 
The  boundary  lines  between  the  epigastric  and  hypochondriac  regions 
correspond  with  the  costal  margins,  and  the  iliac  regions  correspond  to  the 
so-called  inguinal  regions. 

A  second  method  of  dividing  the  abdomen  is  by  a  vertical  and  trans- 
verse line  through  the  umbilicus,  forming  four  quadrants. 

In  reference  to  the  various  landmarks,  one  often  measures  distances 
by  the  finger-breadth.  The  average  finger-breadth  is  %  inch;  two,  i^i 
inches;  etc. 

A  hand-breadth  averages  3^'^  to  4  inches. 

Preparation  of  the  Patient  and  Technic. — The  patient  should  pref- 
erably lie  in  bed  in  the  dorsal  position,  quite  flat,  with  the  head  on  a  single 
thin  pillow.  The  same  posture  should  be  assumed  if  the  examination 
be  made  on  the  office  table.  The  bedclothing  should  be  drawn  well  down, 
except  the  sheet,  under  cover  of  which  the  nightdress  or  undershirt  should 
be  drawn  up  to  the  lower  sternum,  and  the  sheet  then  folded  down  to  a 
short  distance  above  the  pubes.  The  sheet  may  not  be  required  in  the 
office,  though  generally  preferable. 

The  patient  should  lie  as  symmetrically  as  possible,  with  the  pubic 
spines  at  the  same  level  and  a  good  light  secured.  It  is  of  value  to  make 
an  observation  also  in  the  sitting  or  standing  position,  as  prolapse  of  the 
abdominal  walls  or  viscera  can  thus  be  more  clearly  seen. 

Inspection. — Inspection  should  be  from  the  front,  sides,  and  back. 
It  is  of  great  importance.  With  excessive  abdominal  distention  the 
skin  is  smooth,  shining,  and  stretched.  Copper-colored,  scaly,  somewhat 
circular  spots  are  significant  of  secondary  syphilis;  and  whitish  streaks,  or 
striae,  of  long-continued  distention,  such  as  from  pregnancy  or  ascites. 

Typhoid  eruption  or  exanthemata  may  in  some  cases  be  in  evidence. 
Glandular  enlargements  in  the  groin  or  old  scars  are  suggestive  erf  venereal 
infection.     Inguinal,  umbilical,  or  femoral  hernia  may  be  observed. 

Inspection  of  the  blood-vessels  often  affords  valuable  information. 
Enlarged  veins  radiating  from  the  umbilicus  (the  caput  medusae)  are 
significant  of  portal  obstruction,  cirrhosis,  or  tumor  of  the  liver.  General 
enlargement  of  the  abdominal  veins  may  be  present  in  similar  conditions, 
or  from  pressure  on  the  venae  cavae  by  thoracic  or  abdominal  tumors. 
Distended  veins  lying  over  the  liver  in  the  right  lower  thorax  are  also 
suggestive.  If  a  dilated  lateral  vein  is  present  running  up  the  right 
midaxillary  line,  it  should  be  emptied  by  massage,  and  the  method  of  its 
refilling  carefully  observed.  If  the  portal  vein,  or  the  inferior  vena  cava, 
is  obstructed,  the  direction  is  upward;  but  if  the  superior  vena  cava  is 
pressed  upon,  the  direction  is  downward. 


GENERAL   METHODS    OF   PHYSICAL   EXAMINATION 


67 


Distention  of  the  veins  in  the  pubic  region  alone  shows  some  probable 
obstruction  below  the  liver. 

Enlarged  epigastric  arteries  are  diagnostic  of  obstruction  of  the 
aorta  or  iliacs. 

An  umbihcus  that  protrudes  is  suggestive  of  hernia,  ascites,  pregnancy, 
or  some  form  of  abdominal  distention. 

Absence  of  respiratory  abdominal  movements,  with  accentuation 
of  thoracic  respiration,  is  significant  of  peritonitis. 

Peristaltic  unrest  (visible  peristalsis)  is  usually  diagnostic  of  stenosis 
of  the  pylorus  or  intestines  or  of  intestinal  obstruction.  It  may  rarely 
occur  normally  in  thin  persons. 

Stomach  Stiffening  of  Cohnheim. — On  stroking  the  epigastrium,  the 
stomach-walls  are  seen  to  stiffen  and  peristaltic  waves  appear.  These 
indicate  some  obstructive  lesion  of 
the  pylorus. 

Peristalsis. — One  can  at  times 
infer  the  site  of  the  obstruction  by 
the  location  and  character  of  the 
peristalsis.  The  waves  run  in  the 
stomach  from  left  to  right  and  in 
the  transverse  colon  from  right  to 
left.  If  the  obstruction  is  near 
the  ileocecal  valve,  the  swollen  and 
moving  coils  of  the  intestine  lie 
one  above  the  other  in  the  central 
part  of  the  abdomen  (ladder 
pattern). 

If  the  constriction  is  lower 
down  in  the  large  intestine,  the 
distention  is  chiefly  visible  in  the 
course  of  the  colon  (in  the  cir- 
cumference of  the  abdomen).  A 
recurring  protuberance  at  one 
point,  disappearing  with  a  loud 
sound,  is  probably  near  the  point 
of  stenosis.  Finally  peristalsis 
may  dissappear  and  we  may  have 
the  barrel-shaped  abdomen  of 
chronic  obstruction. 

Protrusion  from  a  tumor  can  at  times  be  observed. 

Method  of  Abdominal  Palpation. — The  right  hand  should  be  warmed 
and  laid  flat  upon  the  surface  of  the  abdomen,  the  physician  sitting  to  the 
right  of  the  patient  (Fig.  27). 

Palpation  should  be  at  first  with  somewhat  circular  pressing  move- 
ments, sliding  the  skin  over  the  parts  beneath,  and  passing  from  one 
portion  of  the  abdomen  to  another.  One  should  not  poke  suddenly  with 
the  finger-tips.  Gradually  deeper  localized  palpation  may  be  made  with 
the  finger-pulps  to  determine  the  presence  of  tender  spots,  or  the  shape, 
size,  and  mobility  of  existing  masses  or  swellings. 


Fig.  27. — Abdominal  palpation. 


68 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


The  facial  appearance  of  the  patient  rather  than  the  verbal  expression 
tells  whether  true  pain  is  present.  Tenderness  suggests  inflammation  or 
ulceration.  McBurney's  point  should  always  be  explored  for  appendicitis, 
and  also  Morris'  point  and  the  left  lumbar  ganglia,  Meltzer's  method  for 
determination  of  appendicitis  should  be  used  and  the  Blumberg  sign  for 
peritonitis  should  be  applied  over  the  appendix,  gall-bladder,  etc.  The 
head  zones  for  the  appendix,  gall-bladder  and  stomach  should  be  tested 
for.  In  chronic  cases  of  appendicitis,  the  Rovsing-Chase,  Meltzer's,  or 
Bastedo's  method  could  be  tried.  They  are  all  described  in  the  chapter 
on  appendicitis.  Robson's  point  for  pancreatitis,  Murphy's  point  over  the 
gall-bladder,  Brewer's  point  of  tenderness,  at  the  costo-vertebral  angles 
over  the  kidneys,  Moynihan's  point  over  the  duodenum  and  the  epigastric 
and  left  dorsal  tenderness  of  gastric  ulcer  should  all  be  tested  for.     Right 

dorsal  tenderness,  slightly  lower 
than  the  left  dorsal  for  gastric  ulcer, 
occurs  at  times  with  gall-bladder  in- 
flammation (Boas  point). 

If  firm  pressure  elicits  tenderness, 
it  is  apt  to  be  real  and  deep  seated, 
rather  than  a  surface  lesion  or  hyper- 
esthesia. 

If  hysteria  is  suspected,  the  pa- 
tient's attention  can  be  diverted  by 
pressing  on  a  different  part  of  the 
surface  with  one  hand,  while  the  other 
hand  explores  the  original  seat  of 
pain  complained  of.  Absence  of 
true  tenderness  .  is  thus  frequently 
revealed. 

If  the  abdominal  muscles  are  con- 
tracted, the  knees  and  thighs  should 
be  flexed  and  a  pillow  placed  be- 
neath the  head  and  shoulders  to 
secure  relaxation.  The  flexion  of  the 
lower  limbs  I  believe  preferable  in 
every  case.  Deep  and  rapid  respira- 
tions at  the  end  of  expiration  relax 
the  muscles  momentarily  and  render  examination  more  easy.  This 
method  aids  in  differentiation,  whether  the  mass  felt  is  due  to  contrac- 
tion of  the  belly  of  a  muscle,  such  as  of  the  rectus,  and  whether  a  tumor 
is  movable  with  respiration.  Howard  Kelly  recommends  vibratory  move- 
ments with  the  fingers  while  palpating. 

In  some  cases  reinforced  palpation,  the  left  hand  exerting  pressure 
over  the  right,  as  in  Fig.  28,  is  of  value,  especially  in  examination  of  the 
deeper  organs.  During  examination  forced  respiration  should  be  taken, 
and  at  each  expiration  the  abdominal  wall  should  be  pressed  upon  firmly, 
maintaining  during  inspiration  the  ground  which  has  been  gained.  This 
method  is  of  special  service  in  determining  a  chronic  enlarged  appendix. 
If  there  is  fluid  in  the  peritoneal  cavity  and  one  desires  to  palpate 


Fig.  28. — Reinforced  palpation. 


GENERAL  METHODS  OF  PHYSICAL  EXAMINATION        69 

an  organ  which  is  obscured  by  its  presence,  sudden  deep  pressure  with  the 
finger-tips  ("dipping")  will  displace  the  fluid.  In  some  cases  a  general 
anesthetic  may  be  necessary  for  a  thorough  examination. 

All  the  regions  of  the  abdomen  should  be  explored,  the  umbilical, 
the  inguinal,  and  femoral  regions  being  examined  for  hernia. 

Bimanual  Method. — When  the  lateral  regions  are  examined,  both 
hands  should  be  employed,  one  being  slipped  under  the  body  so  as  to  make 
forward  pressure  between  the  last  rib  and  iliac  crest,  thus  pushing  forward 
the  structure  against  the  examining  hand  in  front. 

At  times  it  may  be  of  service  to  examine  in  the  knee-chest  position, 
or  with  the  patient  standing  and  leaning  forward,  supporting  himself 
with  the  hands  by  a  table  or  chair.  If  he  is  very  fat,  it  is  often  useful  to 
have  him  turn  partly  on  the  side,  thus  "spilling"  the  intestines  and  fatty 
abdominal  walls  away  from  the  region  under  investigation. 

Digital  rectal  and  vaginal  examination  are  advised  in  all  cases,  especially 
when  the  lesion  is  suspected  in  the  lower  third  of  the  abdomen. 

There  is  a  method  of  abdominal  examination  used  abroad  which  I 
have  not  seen  recommended  in  our  text-books.  This  is  the  practice 
of  making  abdominal,  or  bimanual,  vaginal  examination  of  the  patient 
while  in  a  very  hot  bath.  In  many  instances  the  abdominal  relaxation 
thus  obtained  nearly  equals  that  while  under  an  anesthetic,  with  the 
a(^ditional  advantage  that  the  patient  can  help  the  examiner  by  volun- 
tary movements,  such  as  deep  inspiration,  holding  the  breath,  etc.  The 
examination  can  be  made  in  an  ordinary  bath-tub  in  water  as  hot  as 
the  patient  can  bear.  If  it  is  necessary  to  have  the  patient  higher  in  the 
tub,  a  long  sheet  can  be  let  down  over  the  tub  into  the  water  and  fastened 
about  the  ends  of  the  tub  by  knotting  the  corners  under  the  rolling  edge, 
or  by  passing  clothesline  beneath  the  tub.  The  patient  is  thus  suspended 
in  a  hammock. 

Movable  Kidney  suggests  gastroptosis. 

The  Recti  Muscles. — Diastasis  of  the  recti  muscles  suggests  gastroptosis. 

Rigidity  of  one  or  both  of  the  recti  muscles  is  of  great  diagnostic  im- 
portance, being  significant  of  peritoneal  irritation,  local  peritonitis 
(if  one  muscle  be  involved),  or  general  peritonitis  if  both  recti  and  all  the 
abdominal  muscles  are  affected. 

Occasionally  a  rigid  rectus  is  found  on  the  side  of  a  pneumonia  or 
diaphragmatic  pleurisy. 

The  upper  segments^  of  one  or  both  recti  may  be  rigid  in  abscess  of  the 
liver,  or  in  subphrenic  abscess,  or  of  the  right  rectus  in  acute  cholecystitis ; 
the  right  rectus,  especially  the  lower  segment,  in  appendicitis;  and  the 
lower  left  rectus  in  diverticulitis,   or  in  left-sided  pelvic  inflammation. 

Boston's  Method  of  Double  Palpation. — Boston-  recommends  a  special 
technic  in  palpation  which  I  have  sometimes  found  of  service.  He  em- 
ploys the  index-fingers  of  his  two  hands  and  compares  the  degree  of 
tension  over  various  portions  of  the  abdominal  surface.  In  normal  sub- 
jects, in  the  dorsal  position  with  the  thighs  flexed,  there  is  a  slight  increase 

1  The  upper  right  rectus  may  be  rigid  in  duodenal  ulcer,  and  the  upper  left  rectus 
in  gastric  ulcer,  or  phlegmonous  gastritis. 

2  N.  Y.  Med.  Jour.,  Nov.  i,  1913. 


yo  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

in  tension  below  the  right  margin  of  the  ribs  (hepatic  tension).  This  area 
when  compared  with  the  same  region  in  the  left  upper  abdominal  quad- 
rant offers  slightly  more  resistance  to  the  palpating  finger.  Comparing 
the  two  sides  of  the  abdomen  up  to  2  inches  above  the  level  of  the  umbilicus, 
there  is  the  same  degree  of  resistance  offered  to  the  two  palpating  fingers. 
No  difference  in  the  degree  of  resistance  on  the  two  sides  of  the  abdomen 
below  the  umbilicus  can  be  appreciated  during  health.  Begin  on  each  side 
immediately  above  Poupart's  ligament,  ascending  in  lines  drawn  through 
its  center  to  the  costal  border.  The  two  halves  of  the  abdomen  should- 
be  compared  at  equal  levels  as  one  ascends.  The  entire  abdomen  should 
be  palpated  ascending  on  each  side  from  the  inferior  abdominal  re- 
gion with  the  index-finger — simultaneously  and  at  the  same  level — 
to  the  costal  margin,  following  lines  approximately  2  inches  to  the  right 
and  the  same  distance  to  the  left  of  the  original  lines  first  mentioned. 
One  can  elicit  slight  localized  increase  in  tension  even  over  commencing 
lesions,  such  as  enlargement  of  the  liver,  spleen,  kidney,  uterus,  cystic  and 
ovarian  growths,  fecal  impaction,  early  carcinoma,  etc.  Prolapse  of  a 
viscus  causes  lessened  resistance  to  the  finger  when  palpating  over  its 
normal  position  and  increased  tension  over  its  abnormal  position.  Local- 
ized inflammation  is  accompanied  by  undue  tension  over  that  area,  as 
in  acute  appendicitis,  pyosalpinx,  gastric  cancer  and  any  condition  ac- 
companied by  local  peritonitis.  As  posture  may  alter  the  degree  of 
tension,  this  method  should  be  carried  out  also  with  the  patient  on  the 
right  and  left  side  and  also  standing. 

Mensuration  of  the  circumference  of  the  abdomen  at  the  level  of 
the  umbilicus  and  of  the  length  of  its  anterior  wall  from  the  ensiform 
to  the  symphysis,  are  of  use  in  noting  the  increase  in  ascites  or  the  growth 
of  a  large  tumor.  An  uneven  protuberant  surface  is  characteristic  of  a 
malignant  growth;  an  even  surface  is  more  often  found  with  benignant 
neoplasms  or  intussusception.  A  fecal  tumor  can  usually  be  indented, 
and  as  the  finger  is  raised  the  intestinal  wall  slips  from  the  mass. 
(Gersuny's  symptom). 

Percussion  of  the  Abdomen. — With  the  exception  of  pulmonary  reso- 
nance, which  we  note  in  defining  the  upper  limits  of  the  stomach  and 
liver,  and  splenic  and  hepatic  dulness,  the  normal  abdomen  is  tympanitic. 
From  the  presence  of  food  in  the  stomach  or  fecal  accumulation  in  the 
intestines  there  are  variations,  with  resulting  dulness  or  even  flatness. 
The  percussion  note  over  the  cecum,  the  sigmoid  flexure  and  lower  part 
of  the  descending  colon  is  quite  frequently  dull,  owing  to  the  tendency 
to  fecal  accumulation  in  these  regions. 

In  general,  we  may  say  that  the  pitch  of  the  resonant  note  varies 
with  the  size  of  the  air  space  and  the  degree  of  tension  of  the  containing 
cavity;  the  smaller  the  air  space  and  the  greater  the  tension,  the  higher  is 
the  pitch.  Hence,  the  empty  stomach  and  colon  would  afford  a  lower 
pitched  note  than  the  small  intestine. 

The  presence  of  food  and  liquid  in  the  stomach  modifies  the  results 
of  percussion,  as  do  also  feces  in  the  large  intestine.  For  example,  with 
an  empty  stomach  we  have  tympanites;  and  then  quite  frequently  a 
change  in  note  over  the  transverse  colon  to  dulness  or  even  flatness;  or 


GENERAL  METHODS  OF  PHYSICAL  EXAMINATION 


71 


with  the  partially  full  stomach  and  empty  intestine,  tympanites,  above, 
then  dulness  or  flatness  over  the  contents  and  intestinal  tympanites 
below.  It  is  well,  therefore,  to  have  the  large  intestine  cleared  out  by 
enema  before  examination.  Practically  we  find  in  many  cases  stomach 
tympanites  with  change  in  note  over  the  colon  due  to  some  contents. 


Fig.  29. — Simple  percussion. 

Among  the  best  methods  of  percussion  are  simple  percussion  with 
the  finger  or  hammer,  flicking  percussion,  auscultatory  percussion,  and  the 
"scratch  method"  of  auscultation. 

.  In  simple  percussion,  the  middle  finger  of  the  left  hand  should  be 
laid  flat  on  the  abdomen  (the  pleximeter)  and  the  middle  finger  of  the 
right  hand,  bent  at  right  angles,  should  be  employed  as  the  plexor,  as 


Fig.  30. — Percussion  hammer. 

depicted  in  Fig.  29.  The  other  fingers  and  thumb  should  be  folded  into 
the  palm  of  the  hand. 

In  Fig.  30  is  shown  the  method  with  the  percussion  hammer  and 
the  correct  position.  The  finger  is  preferable  as  a  pleximeter,  as  the 
rubber  instruments  interfere  with  the  sounds. 

Light  percussion  ("piano  percussion")  was  first  suggested  by  John 
B.  Murphy  to  determine  the  seat  of  the  primary  focus  of  a  general  peri- 


72  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

tonitis.  H.  Neuhof^  advocates  the  employment  of  deep  percussion  in 
subacute  and  subsiding  intraperitoneal  infections  as  an  aid  to  localizing 
the  lesion.  A  fair  amount  of  percussion  force  may  be  required,  the 
pleximeter  finger  being  pressed  in  deeply.  If  this  gives  doubtful  results 
then  tap  vigorously  the  abdominal  wall  with  the  crooked  middle  finger  of 
the  right  hand.  The  presence  of  percussion  tenderness  by  these  methods 
locates  the  trouble.  This  is  of  particular  value  in  stout  patients  who  are 
difficult  to  palpate. 

"Flicking  percussion"  is  useful  in  detecting  slight  degrees  of  dulness. 

The  forefinger  or  middle  finger  of  the  left  hand  should  be  placed 
nail  downward  on  the  surface;  the  middle  finger  of  the  right  hand  is 
well  flexed,  so  that  the  nail  is  pressed  against  the  palmar  surface  of  the 
thumb.  It  is  then  suddenly  allowed  to  escape,  so  as  to  strike  sharply 
against  the  palmar  surface  of  the  finger  lying  on  the  abdomen  (Fig.  31). 

Auscultatory  percussion  is  probably  of  greatest  value  in  outlining 
contiguous  air-containing  viscera. 


Fig.  31. — Flicking  method  of  percussion. 

The  stethoscope  is  placed  over  the  organ  and  the  normal  note  secured 
by  percussion  close  to  the  instrument.  Then  percussion  is  carried  out, 
beginning  at  some  distance,  from  above,  below,  and  laterally,  and  the 
change  of  note  observed. 

This  method  and  the  "scratch"  method  will  be  described  later  in 
outlining  the  position  of  the  stomach  and  intestines. 

If  the  percussion  note  of  a  deep-seated  mass  is  to  be  elicited,  the 
pleximeter  finger  must  be  pressed  slowly  and  firmly  down  in  order  to 
push  aside  or  compress  air-coils  of  intestine  which  would  mask  the  note. 

If  dulness  is  present  where  it  should  not  exist,  it  should  be  ascertained 
whether  it  disappears  or  shifts  with  changes  in  the  position  of  the  patient, 
i.e.,  whether  it  is  fluid. 

If  the  distention  is  due  to  ascites  (fluid),  the  center  of  the  abdomen 
is  flattened  and  the  lateral  and  dependent  portions  bulge  outward,  pro- 
viding the  fluid  is  not  excessive.  If  it  is  very  great,  the  abdomen  is 
^  Medical  Review  of  Reviews,  June,  191 2. 


Fig.  32- — Relations  of  the  viscera.     Anterior  view;   L,  L,  Lungs;  A,  heart;  B, 
liver;  C,  stomach;  x,  gall-bladder;  D,  colon;  E,  small  intestine. 


GENERAL   METHODS    OF    PHYSICAL    EXAMINATION  73 

arched  and  prominent,  the  umbiHcus  is  bulging  or  stretched,  and  the 
shape  is  not  changed  when  the  posture  is  altered. 

On  percussion,  the  flanks  are  dull  and  the  center  of  the  abdomen 
tympanitic,  as  the  intestines  float  to  the  highest  point.  Unless  the 
quantity  of  fluid  is  excessive  the  line  of  dulness  changes  its  position, 
as  the  patient  is  turned  on  the  side,  the  fluid  gravitating  to  the  lowest 
point  and  being  replaced  by  the  tympanitic  intestine.  The  upper  flank, 
previously  dull,  is  now  tympanitic.  If  a  small  amount  of  fluid  is  sus- 
pected, percussion  of  the  umbilical  region  in  the  knee-chest  position  will 
give  dulness  when  it  was  tympanitic  in  the  dorsal  position. 

Fluctuation  may  be  elicited  if  there  is  considerable  fluid. 

The  ulnar  edge  of  a  nurse's  or  assistant's  hand  should  be  pressed 
firmly  on  the  linea  alba,  to  cut  off  muscular  vibrations. 

One  hand  of  the  examiner  is  placed  upon  one  lateral  abdominal 
wall,  while  he  should  tap  sharply  with  the  fingers  on  the  opposite  side. 
If  fluid  is  present,  a  transmitted  wave — at  times  visible — will  be  felt  by 
the  palpating  hand. 

With  tumors,  enlargement  of  the  abdomen  is  not  symmetric.  Per- 
cussion does  not  show  the  uniform  resonance  of  gas  nor  the  lateral  dulness 
and  central  tympanites  of  fluid,  and  palpation  demonstrates  the  solidity 
of  the  mass. 

With  gas,  the  abdomen  is  arched  and  tense,  universally  tympanitic, 
and  fluctuation  cannot  be  obtained. 

Sources  of  Error. — The  segments  of  the  recti  muscles  when  contracted 
may  simulate  a  small  tumor. 

By  insinuating  the  tips  of  the  fingers  under  the  edge  of  the  apparent 
tumor  and  having  the  patient  raise  the  head  and  shoulders,  the  muscle  is 
felt  to  contract  and  thicken. 

A  localized  contraction  of  the  abdominal  muscles  or  a  persistent 
gaseous  distention  of  a  portion  of  the  intestines  ("phantom"  tumor) 
may  be  deceptive.  These  occur,  as  a  rule,  in  hysteric  women  and  are 
dull  or  tympanitic,  depending  on  the  above  conditions.  They  disappear 
during  rapid  forced  respiration  or  under  anesthesia. 

Fitz  believes  that  some  "phantom"  tumors  are  congenital  or  acquired 
dilatation  of  the  colon. 

Auscultation  of  the  Abdomen. — Sounds  in  the  Abdominal  Cavity. 
— In  the  healthy  intestines  there  are  always  bubbling  or  gurgling  sounds 
heard  on  auscultation.  The  entire  absence  of  sound  is  significant  of 
intestinal  paresis. 

With  mechanic  obstruction  the  sounds  are  usually  increased  in  in- 
tensity and  number. 

With  intestinal  paresis,  usually  due  to  peritonitis,  the  heart  and 
respiratory  sounds  may  be  audible  over  the  entire  abdomen.  This 
is  not  true  in  tympanites  due  to  other  causes.  Crepitation  or  friction 
sounds  are  at  times  heard  in  peritonitis,  as  in  perihepatitis  in  the  right 
hypochondrium,  or  in  the  left  hypochondrium  with  perisplenitis. 

The  venous  hum  or  aneurysmal  bruit  of  abdominal  aortic  aneurysm 
can  be  appreciated,  or  occasionally  a  venous  hum  over  the  liver  from 
pressure  on  the  vena  cava.     If  pregnancy  is  present,  there  are  the  fetal 


74 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


heart  sounds.     The  sounds  over  the  stomach  are  of  Httle  diagnostic  value, 
except  the  duration  of  the  swallowing  sound. 


TOPOGRAPHIC  ANATOMY 

The  position  and  relations  of  the  stomach  and  intestines  have  been 
described,  but  for  the  purpose  of  physical  diagnosis  we  must  briefly  refer 
to  the  normal  relations  of  the  other  abdominal  viscera. 

In  Fig.  32  are  depicted  diagrammatically  the  relations  of  the  organs 
on  the  anterior  surface  of  the  body,  and  in  Fig.  33  the  relations  on  the 
posterior  surface. 


-..:.  J      1.,    -i 
Fig.  34. — Delimitation  of  the  normal  liver  (diagrammatic) :  G,  Gall-bladder. 

The  Liver. — The  general  shape  is  that  of  a  wedge  with  its  base  in 
the  right  hypochondrium,  the  upper  surface  lying  in  relation  to  the  vault 
of  the  diaphragm,  and  its  lower  surface  with  the  stomach,  duodenum,  gall- 
bladder, transverse  colon,  and  small  intestine;  its  anterior,  lateral,  and 
posterior  portions  are  in  relation  with  the  abdominal  parietes  and  lower 
right  ribs. 

Delimitation  of  the  Normal  Liver. — Mark  a  point  i  (Fig.  34)  at  the 
lower  border  of  the  fifth  rib,  between  the  left  parasternal  and  mammillary 
lines,  or  about  2  to  2>^  inches  from  the  left  edge  of  the  sternum. 

Point  2  lies  in  the  fourth  right  intercostal  space  in  the  mammillary 
line.  From  2  to  i  draw  a  connecting  line,  slightly  convex  upward  on  the 
right  half  and  concave  on  the  left,  curving  down  at  the  lowest  point 
to  the  base  of  the  ensiform  appendix. 

From  2  draw  a  line  nearly  horizontally  to  the  right  and  posteriorly, 
which  should  cut  the  midaxillary  line  in  the  seventh  space  and  the  scapular 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION 


75 


line  in  the  ninth  space,  to  the  midspinal  line.     This  line,  front,  side,  and 
back,  corresponds  to  the  upper  border  of  the  liver. 

To  delimit  the  lower  border,  mark  point  4  in  the  median  line  (linea 
alba)  about  a  hand-breadth  (3^^  to  4  inches)  below  the  base  of  the 
ensiform  process  of  the  sternum. 

Mark  point  3  at  the  lower  edge  of  the  ninth  right  costal  cartilage, 
and  another  point  5  at  the  edge  of  the  left  costal  arch  on  a  level  with  the 
lower  border  of  the  sixth  rib.  A  line  should  then  be  drawn  from  3  to  4 
upward  and  to  the  patient's  left. 
At  4  is  indicated  the  notch  between 
the  liver  lobes.  From  4  a  slightly- 
curved  line  to  I,  passing  through  5, 
should  next  ■  be  drawn.  The  line 
from  3  to  I  indicates  the  lower  an- 
terior border  of  the  organ. 

From  point  3  draw  a  line  back- 
ward and  to  the  patient's  right,  cut- 
ting the  tenth  intercostal  space  in  the 
midaxillary  line,  from  which  point  it 
joins  the  spine  at  a  level  of  the  elev- 
enth rib  (Fig.  35).  This  line  demarks 
the  lower  border  of  the  liver  laterally 
and  posteriorly,  and  is  a  continuation 
of  the  anterior-inferior  border. 

This  illustration  shows  diagram- 
matically  the  relations  of  the  lower 
borders  of  the  lung,  pleura,  and  liver 
in  the  midaxillary  line. 

The  left  lobe  lies  to  the  left  of  the 
linea  alba  and  extends  nearly  to  the 
nipple,  the  notch  lying  in  the  midline. 
In  the  right  mammillary  line  the  liver 
extends  from  just  below  the  level  of 
the  nipple  to  the  costal  margin. 

The  horizontal  shadings  in  Fig.  34 
show  the  portion  of  liver  overlapped 
by  lung,  and  the  vertical  shadings,  that  overlapped  by  the  heart. 

The  gall-bladder,  which  is  pear  shaped,  lies  just  internal  to  the  ninth 
right  costal  cartilage. 


Fig. 


35. — Lower   border   of   liver    (mid- 
axillary line). 


PHYSICAL  EXAMINATION  OF  THE  LIVER  AND  GALL-BLADDER 


Inspection. — The  method  advocated  by  M.  Knapp  I  have  found 
most  practical.  The  patient  stands  with  the  abdomen  uncovered  facing 
a  good  light,  the  examiner  slightly  to  the  patient's  right,  so  as  not  to 
interfere  with  the  exposure  to  light.  The  lower  edge  of  the  enlarged 
liver  shows  on  the  abdomen  as  a  linear  transverse  shadow,  moving  up  and 
down  with  respiration  and  being  especially  prominent  at  the  close  of 
expiration,  when  there  is  a  sudden  check  to  the  movement.     Pulsation 


76  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

can  occasionally  be  observed.  Extreme  enlargement  may  cause  fulness 
in  the  right  hypochondrium. 

An  enlarged  gall-bladder  can  be  appreciated  in  the  same  manner. 
Inspection  may  also  be  made  with  the  patient  in  the  dorsal  position, 
the  examiner  stooping  so  as  to  bring  the  eyes  on  a  level  with  the  abdomen. 

Palpation. — The  head  and  shoulders  should  be  slightly  raised  and 
the  knees  and  thighs  flexed,  the  patient  being  in  the  dorsal  position. 
The  examiner,  sitting  on  the  right  side  of  the  patient,  should  lay  the 
right  hand  flat  on  the  abdomen  below  the  right  costal  arch,  the  fingers 
pointing  upward  and  obliquely  inward  just  to  the  right  of  the  right  rectus. 
Depress  the  fingers  and  feel  for  the  resistance  edge  of  the  liver.  The 
patient  should  be  directed  to  take  deep  respirations,  and  by  pressing  in- 
ward and  upward  with  the  fingers  the  edge  of  the  organ  can  be  felt  to  move 
up  and  down. 

As  the  liver  may  be  enlarged,  palpation  for  its  lower  edge  must  be 
begun  from  the  level  of  the  umbilicus  upward.     It  is  often  necessary 


•Fig.  36.— "Spilling"  the  liver. 

to  feel  for  the  notch  of  the  gall-bladder  or  round  ligament  to  determine 
whether  it  is  the  edge  of  the  liver  which  is  felt  on  palpation.  One  should 
note  whether  the  edge  is  sharp  or  thick,  or  smooth  or  irregular.  In 
some  cases  with  thick  abdominal  walls  the  liver  may  be  "spilled"  against 
the  latter  by  turning  the  patient  on  the  right  side,  as  in  Fig.  36,  thus  render- 
ing palpation  more  easy.  The  hand  in  this  case  may  be  in  the 
reversed  position. 

The  surface  of  the  liver  should  be  palpated,  the  left  lobe  in  the  epi- 
gastrium and  the  portion  projecting  below  the  ribs,  if  it  be  enlarged. 

One  should  observe  whether  it  is  rough,  smooth,  nodular,  or  whether 
large  tumor-like  masses  are  present;  also  whether  it  is  hard  or  soft  and 
fluctuating;  or  if  there  is  a  thrill  (hydatid),  or  friction  during  respiration, 
or  pulsation.  If  the  abdomen  is  distended  the  "dipping"  method  of 
palpation  may  be  necessary. 

The  empty  gall-bladder  is  not  palpable.  If  distended  it  feels  like  a 
smooth  pear-shaped  tumor,  moves  with  respiration,  and  is  movable 
laterally,  unless  there  are  adhesions. 


GENERAL   METHODS    OF   PHYSICAL   EXAMINATION  77 

If  malignant  growth  is  present,  the  gall-bladder  is  irregular  and 
nodular.  If  there  are  many  gall-stones,  Hutchinson  describes  the  feel  as 
of  a  "bag  of  nuts." 

Percussion  of  Liver  and  Gall-bladder. — For  anterior  and  lateral 
percussion  the  patient  should  lie  down;  for  percussion  posteriorly  he 
should  be  sitting  or  standing,  or  if  very  ill,  lying  on  the  belly. 

The  upper  part  of  the  right  lobe  is  overlapped  by  the  lung,  and  of 
the  left  lobe,  a  small  area  is  covered  by  the  left  lung  and  heart. 

Percussion  over  the  covered  part  gives  impaired  pulmonary  resonance, 
or  modified  dulness  (deep,  relative,  or  covered  hepatic  dulness).  The 
part  in  contact  with  the  parietes  gives  absolute  dulness  (superficial  or 
exposed  dulness). 

It  is  necessary  to  delimit  the  entire  area.  Percuss  downward,  first  in 
the  mammillary  line,  beginning  at  the  second  intercostal  space;  then  in 
the  midaxillary  line  from  the  fourth  interspace,  and  in  the  scapular  line 
from  the  angle  of  the  scapula.  Percussion  should  then  be  made  from 
below  upward,  in  the  midline  from  the  umbilicus  and  from  lateral  and 
posterior  points  below  the  ribs. 

Covered  Hepatic  Dulness. — Strong  percussion  should  be  employed, 
commencing  above  in  the  areas  noted,  and  watching  for  the  change  from 
pure  pulmonary  resonance  to  impaired  resonance,  which  denotes  the 
presence  of  the  liver.  Impaired  resonance  is  found  normally  in  the 
fourth  space  in  the  mammillary  line;  in  the  seventh  space  in  the  midaxil- 
lary line;  and  in  the  ninth  space  in  the  scapular  line. 

Upper  Limit  of  Exposed  (Absolute)  Hepatic  Dulness. — Gentle  per- 
cussion should  then  be  employed  and  normally  absolute  liver  dulness 
appears  in  the  mammillary  line  at  the  sixth  rib;  midaxillary  line  at  the 
eighth  rib;  and  in  the  scapular  line  at  the  tenth  rib. 

Lower  Limit  of  Hepatic  Dulness. — Gentle  percussion  along  the  lines 
previously  indicated  from  below  upward  will  differentiate  between  tym- 
panites and  hepatic  dulness.  The  lower  limit  normally  is  in  the  median 
line  anteriorly  a  hand-breadth  (3^^  to  4  inches)  below  the  ensiform;  in  the 
mammillary  line,  the  tenth  space.  In  the  scapular  line,  it  joins  the  dulness 
of  the  right  kidney. 

The  vertical  width  of  liver  dulness  is  normally  in  the  mammillary 
line  4  inches;  in  the  midaxillary,  6  inches;  in  the  scapular,  3  inches. 

Percussion  of  the  Gall-bladder. — This  is  only  possible  when  it  is  dis- 
tended or  enlarged,  in  which  event  there  is  an  area  of  dulness  projecting 
downward  and  inward  from  the  lower  border  of  the  liver  and  continuous 
with  the  dulness  of  the  latter.  In  some  cases  the  transverse  colon  may 
pass  over  the  neck  of  the  distended  gall-bladder  and  separate  its  dulness 
from  that  of  the  liver  by  a  tympanitic  area.  This  is  important  to  re- 
member. 

A  uscultatory  Percussion  of  the  Liver. — The  stethoscope  should  be  placed 
over  the  middle  of  the  area  of  the  liver  anteriorly,  laterally,  and  posteriorly, 
and  percussion  be  carried  out  on  the  lines  already  described.  As  a 
rule,  simple  percussion  is  sufficient;  but  the  auscultatory  method  is  of 
special  value  to  determine  whether  a  tumor  is  connected  with  the  liver  or 
not. 


70  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Thus,  in  Fig.  37  the  stethoscope  is  placed  over  point  S.  The  note 
over  the  tumor  T  resembles  more  closely  in  intensity  and  quality  the 
percussion  note  over  the  liver  at  C  than  it  does  over  the  point  A. 

1.  Chmiffard^s^  Method  of  Percussion  for  Hydatid  Cyst  of  the  Liver. — 
Place  the  left  hand  under  the  right  side  of  the  thorax  of  the  recumbent 
patient  and  percuss  with  the  right  hand,  with  short  strokes,  the  anterior 
wall  of  the  thorax  as  well  as  the  epigastrium.  Transmission  of  waves  or 
vibrations  to  the  left  hand  through  the  thorax  indicates  cystic  disease. 

2.  Suprahepatic  Ballottement. — The  left  hand  is  placed  on  the  anterior 
aspect  of  thorax  at  the  level  of  the  second  and  third  intercostal  spaces, 
while  the  right  hand  hooks  around  the  lower  margin  of  the  liver  and  the 

attempt  is  made  to  drive  it 
^^  upward  by  a  series  of  sharp 
pulls.  At  each  pull  a  slight 
impulse  is  transmitted  up  to 
the  left  hand,  when  there  is 
cystic  disease. 

3.  Transthoracic  Hydatid 
Fremitus. — This  is  elicited 
when  the  patient  is  erect. 
The  left  hand  is  placed  across 
the  back  below  the  lower  angle 
of  the  left  scapula  and  per- 
-Tumor  of  liver.  ceives,    in    hydatid    disease, 

light  undulatory  vibrations, 
when  the  fifth  or  sixth  rib  is  percussed  anteriorly  with  the  right  index- 
finger. 

General  enlargement  of  the  liver  may  be  due  to  passive  congestion, 
usually  from  valvular  disease  of  the  heart,  amyloid  disease,  cancer,  fatty 
infiltration,  hypertrophic  cirrhosis,  leukemia,  abscess,  gummd,  or,  rarely, 
Weil's  disease. 

Circumscribed  enlargement  of  the  liver,  i.e.,  of  the  left  lobe,  is  usually 
due  to  abscess,  hydatid  cyst,  gumma,  or  cancer. 

Downward  displacement  of  the  liver  is  caused  by  various  intra- 
thoracic lesions,  such  as  emphysema,  effusions,  etc.,  by  subphrenic  abscess, 
or  as  a  part  of  a  general  ptosis  of  the  viscera.  In  downward  displace- 
ment the  upper  surface,  especially  of  the  left  lobe,  is  readily  accessible 
to  palpation  and  presents  a  rounded  surface. 

A  prolapsed  liver  does  not  move  as  freely  with  respiration,  on  account 
of  its  separation  from  the  diaphragm. 

The  consistence  of  the  liver  is  somewhat  diagnostic.  It  is  abnormally 
hard,  dense,  arid  resistant  in  cirrhosis,  carcinoma,  amyloid  disease,  or 
syphilis. 

A  fluctuating  swelling  at  the  lower  border  may  be  a  distended  gall- 
bladder, abscess,  or  hydatid  cyst. 

The  surface  is  smooth  in  fatty  infiltration  or  degeneration,  in  passive 
congestion,  and  in  amyloid  disease;  it  is  rough  in  tubercular  peritonitis 
and  granular  to  the  feel  in  cirrhosis. 

'  Lejars,  Presse  Medicale,  April  25,  1914. 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION 


79 


Hard  nodules,  varying  in  size,  are  suggestive  of  cancer;  smooth, 
elevated  prominences  occur  with  gummata.  A  smooth  projection  may- 
be due  to  abscess  or  cyst. 

Topography  of  the  Pancreas. — The  pancreas  (Fig.  38)  lies  about 
3  inches  above  the  umbilicus,  midway  between  the  navel  and  the  ensiform 
appendix,  corresponding  to  the  level  of  the  first  lumbar  vertebra. 

It  is  about  6  inches  long  and  lies  deep  in  the  epigastrium,  transversely 
across  the  spine,  with  its  head  resting  in  the  curve  of  the  duodenum  and  its 
tail  extending  to  the  spleen.  The  stomach  covers  it  in  front.  It  is  rarely 
accessible  to  direct  examination.  The  head  of  the  organ  lies  in  close 
relation  to  the  inferior  vena  cava,  portal  vein,  and  common  bile-duct, 
which  are  posterior.  A  cancer  or  growth  of  the  head  of  the  pancreas  may 
press  upon  these  blood-vessels  and  cause  edema  and  ascites,  or  upon 


Fig.  38. — ^The  pancreas. 


the  bile-duct  and  produce  presistent  jaundice  with  dilatation  of  the 
gall-bladder. 

Pain,  fatty  diarrhea,  ascites,  glycosuria,  and  jaundice  may  result 
from  pancreatic  disease. 

The  diseases  in  which  these  conditions  are  present  are  acute  hemor- 
rhagic or  suppurative  pancreatitis,  chronic  pancreatitis,  and  tumor — 
either  carcinomatous  or  cystic. 

Under  Diseases  of  the  Pancreas  the  author  refers  his  readers  for  a 
complete  description  of  the  subject. 

Physical  Examination. — Normally  the  pancreas  cannot  be  palpated 
unless  the  patient  is  extremfely  emaciated. 

An  important  physical  sign  of  pancreatic  disease  is  the  presence  oj  a 
tumor  in  the  median  portion  of  the  epigastrium,  midway  between  the 
navel  and  the  ensiform  process.     It  is  deep  seated  and  often  nothing 


8o  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

more  than  a  sense  oj  resistance  can  be  appreciated  by  the  palpating  hand. 
Tenderness  at  Robson's  point  also  is  diagnostic  of  pancreatic  disease. 

Topography  of  the  Spleen. — The  spleen  is  oval,  flattened  in  shape, 
and  lies  in  the  left  hypochondriac  region,  measuring  on  an  average  5  by 
3  inches.  It  reaches  from  a  point  i>^  inches  from  the  midspinal  line 
posteriorly  nearly  to  the  midaxillary  line,  lying  along  the  ninth,  tenth, 
and  eleventh  ribs,  the  long  axis  being  parallel  with  the  ribs  and  running 
obliquely  forward  and  downward,  as  in  Fig,  41. 

The  lower  two-thirds  of  its  outer  surface  lie  against  the  lateral  ab- 
dominal wall,  and  the  upper  third  is  overlapped  by  the  diaphragm,  which 
separates  it  from  the  lower  border  of  the  left  lung.  The  diaphragm 
lies  above  and  the  left  kidney  posteriorly,  and  it  is  in  contact  elsewhere 
with  the  stomach,  pancreas,  colon,  and  small  intestine. 

The  anterior  border  is  sharp  and  indented  by  two  to  four  notches. 


Fig.  39.- — Examination  of  the  spleen.     "  Spilling  "  the  spleen. 

Physical   Examination   of   the   Spleen. — Inspection. — If    the   spleen 

is  greatly  enlarged,  it  may  be  visible  as  a  protuberance  extending  from 
the  left  hypochondrium  downward  and  inward,  moving  with  respiration. 

Palpation. — With  the  patient  in  the  dorsal  position  and  the  knees 
and  thighs  flexed,  the  examiner  on  the  right  side  of  the  bed  should  lay 
the  right  hand  flat  on  the  abdomen  and  with  the  finger-tips  exert  pressure, 
pushing  obliquely  upward  under  the  left  costal  margin  at  the  tenth 
cartilage.     The  edge  of  the  enlarged  spleen  can,  as  a  rule,  then  be  felt. 

If  it  is  not  palpable,  then  request  the  patient  to  take  deep  breaths, 
when  the  sharp  edge  of  the  organ,  which  is  smooth  and  usually  notched, 
moving  with  respiration,  will  be  felt  riding  over  the  finger-tips  and 
directed  downward  and  inward. 

The  left  hand  may  be  placed  posteriorly  between  the  ends  of  the 
tenth  and  eleventh  ribs  and  firm  pressure  be  made,  so  as  to  tilt  the  organ 
forward  and  thus  make  palpation  more  easy.  Normally  the  spleen  cannot 
be  felt. 

If  the  organ  is  enlarged  a  depression  or  space,  into  which  the  finger- 
tips can  be  sunk,  can  be  detected  at  the  posterior  border  of  the  enlarged 
spleen  between  it  and  the  erector  spinae. 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION  8 1 

An  excellent  method  of  palpation  of  the  spleen  is  shown  in  Fig.  39. 
By  turning  the  patient  on  the  right  side,  combined  with  posterior  pressure, 
palpation  is  rendered  easier. 

It  is  often  necessary  to  differentiate  between  tumor  of  the  left  kidney 
or  spleen. 

The  spleen  is  oval,  moves  with  respiration,  is  notched,  has  a  sharp 
edge,  a  gap  is  present  between  it  and  the  lumbar  muscles,  and  it  has 
no  tympanitic  resonance  over  it. 

The  kidney  is  reniform  in  shape  and  rounded,  has  no  sharp  edge 
or  notch,  and  is  overlaid  by  tympanitic  resonance  (Fig.  40). 

Percussion  of  the  Spleen. — The  patient  may  be  recumbent,  partially 
turned  to  the  right,  midway  between  the  dorsal  and  right  lateral  position, 


,-V  .. 

:!^ 

1 

1    OF   LUN  C 

^H 

i 

OF  R\Q^, 

S| 

i 

i 

jm 

i 

HP 

P 

Fig.  40. — S,  Tumor  of  spleen;  K,  tumor  of  kidney.     Kidney  tumor  overlaid  by  tym- 
panitic colon. 

with  the  left  arm  extended  over  the  head;  or  the  examination  may  be 
made  in  the  sitting  posture.  Percussion  should  be  light,  except  over  the 
posterior  portion  near  the  kidney. 

It  should  be  carried  out  along  the  lines  A,B,C,Dm  Fig.  41.  Anterior 
percussion  at  the  costal  margin  along  the  tenth  rib,  along  A  until  the 
tympanites  of  the  stomach  is  replaced  by  dulness,  usually  at  the  midaxillary 
line.  From  above  percuss  along  B,  commencing  at  the  level  of  the  angle 
of  the  scapula  midway  between  the  posterior  axillary  and  scapular  lines, 
passing  vertically  downward  until  pulmonary  resonance  is  impaired, 
generally  at  the  ninth  rib. 

Percuss  from  below  upward  along  line  C,  commencing  below  the 
border  of  the  ribs,  in  or  slightly  posterior  to  the  posterior  axillary  line, 
and  passing  upward  until  tympanites  become  dull,  usually  at  the  eleventh 
rib. 

6 


82 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Posteriorly  percuss  strongly  from  midspinal  line  at  level  of  the  tenth 
rib  and  along  the  latter. 

Splenic  dulness  should  commence  i^^i  inches  from  the  median  spinal 
line.  It  is  difficult  to  determine.  -  The  area  of  splenic  dulness  is  oval, 
2  to  2>^  inches  by  3  to  sH  inches.  Dulness  of  over  ^y^  inches,  on  vertical 
percussion,  shows  enlargement. 

Pleuritic  effusion,  consolidation  at  the  left  base  of  the  lung,  and  fecal 
accumulation  in  the  splenic  flexure,  may  obscure  percussion  of  the  spleen. 
Palpation  is  the  most  important  method  and  the  most  accurate. 

Acute   enlargement   of   the  spleen   occurs   with   infectious   diseases, 


JMlDAXlLLARyilc 

LINE 


Fig.  41. — Lines  for  percussion  of  spleen. 


such  as  typhoid,  malaria,  etc.,  and, in  septic  processes;  chronic  enlarge- 
ment, with  leukemia,  malaria,  cirrhosis  of  the  liver,  amyloid  disease, 
pernicious  anemia,  etc.  The  organ  may  be  displaced  downward  by 
intrathoracic  pressure. 

Abscess,  carcinoma,  or  hydatids  may  cause  an  unequal  enlargement. 
Liver  and  spleen  may  be  enlarged  together  in  passive  congestion,  cirrhosis 
of  the  liver,  leukemia,  and  in  amyloid  disease. 

A  floating  spleen  may  occur  as  a  result  of  congenital  laxity  of  its 
ligaments  or  to  overstretching  from  the  increased  size  or  weight.  It 
may  be  part  of  visceroptosis,  usually  in  women.  It  is  recognized  by  its 
mobility,  shape,  sharp  edge,  and  notches. 


GENERAL    METHODS    OF    PHYSICAL    EXAMINATION 


83 


Topography  of  the  Kidneys.^ — The  two  kidneys  lie  against  the  posterior 
abdominal  wall,  one  on  each  side  of  the  spinal  column,  in  beds  of  fat  and 
connective  tissue.  They  are  of  reniform  shape.  The  upper  end  of  the 
right  kidney  is  in  contact  with  the  liver,  and  the  left  kidney  with  the 
spleen.  They  are  retroperitoneal,  the  ascending  and  descending  colon 
respectively  lying  in  relation  in  front.  The  right  kidney  lies  about  >^ 
inch  lower  than  the  left.  Each  organ  is  about  4  inches  long,  2  to  2^ 
inches  in  breadth,  and  i  inch  thick. 

Surface  Relations  of  the  Kidtieys. — Draw  a  horizontal  line  through 
the  upper  margin  of  the  umbilicus;  prolong  the  mammillary  lines  on 
each  side  downward  until  they  intersect  this  horizontal  line.  The 
points  of  intersection  lie  about  3  inches  on  each  side  of  the  median  line. 


Fig.  42. — Anterior  surface  of  kidneys. 

From  the  intersections  measure  upward  i  inch  on  the  right  and 
i^i  inches  on  the  left  mammillary  line,  and  draw  on  each  side  a  short 
horizontal  line.     The  lower  ends  of  the  kidneys  lie  at  these  levels  (Fig.  42). 

One  can  measure  3  inches  on  each  side  along  the  horizontal  line  and 
then  upward,  without  drawing  the  mammillary  line.  The  kidneys  extend 
upward  and  inward  about  4  inches,  one-third  to  the  outer  side  and  two- 
thirds  to  the  inner  side  of  the  vertical  lines. 

Posterior  Surface  Relations  of  the  Kidneys. — Draw  a  horizontal  line 
across  the  back  at  the  level  of  the  tip  of  the  spine  of  the  eleventh  dorsal 
vertebra;  a  second  line  at  a  level  of  the  tip  of  the  spine  of  the  third  lumbar 
vertebra.  On  each  side  draw  a  vertical  line  from  the  upper  to  the  lower 
horizontal  lines,  i  inch  from  the  median  line  of  the  spine,  and  second 
vertical  lines  2^4  inches  away  from  the  first  vertical  lines.  Within  these 
outer  parallelograms  lie  the  kidneys  (Fig.  43). 

The  lower  ends  of  these  organs  lie  from  i  to  iH  inches  above  the 
iliac  crests,  the  right  ^i  inch  lower  than  the  left.     About  a  third  of  the 


84 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


upper  ends  are  covered  by  the  eleventh  and  twelfth  ribs;  the  liver  overlaps 
the  right  kidney  and  the  spleen  the  left. 

Physical  Examination  of  the  Kidneys. — Inspection  is  seldom  of 
service;  palpation  is  most  valuable;  percussion  is  often  uncertain. 

Inspection. — A  large  tumor  of  the  kidneys  may  be  visible  in  the 
anterior  lumbar  regions,  extending  into  the  umbilical  region,  with  outward 
bulging  of  the  ribs  on  the  affected  side,  such  as  in  the  case  of  sarcoma, 
hydronephrosis,  or  cyst.  ■  A  perinephritic  abscess  may  become  visible  as 
a  swelling  in  the  posterior  lumbar  region. 

Palpation. — This  is  most  important.  There  are  several  methods 
described,  of  which  the  two  following  are  the  most  practical: 


Fig.  43. — Posterior  surface  relations  of  kidneys:  ^,  Lower  border  of  lungs;  B,  level 
of  spine  of  eleventh  dorsal  vertebra;  C,  lower  border  of  liver;  D,  level  of  spine  of  third 
lumbar  vertebra;  E,  colon. 

Method  I. — The  patient  lies  in  the  dorsal  position,  with  the  knees 
and  thighs  flexed,  and  the  head  is  slightly  raised  to  secure  perfect  re- 
laxation. If  the  right  kidney  is  to  be  examined,  the  left  hand  is  slipped 
under  the  back,  so  that  it  rests  on  the  two  lower  ribs  and  the  lumbar 
space  below  them.  The  right  hand  is  laid  flat  on  the  abdomen  in  front, 
resting  below  the  costal  margin  to  the  outer  side  of  the  rectus,  as  in  Fig.  44. 

The  patient  should  take  deep  and  slow  respirations,  and  during 
expiration  firm  pressure  should  be  made  with  the  fingers  in  front  against 
posterior  counterpressure,  so  that  the  kidney  may  be  grasped  between  the 
hands. 

If  the  kidney  is  normal  in  position  and  size,  the  extreme  lower  edge 


GENERAL  METHODS  OF  PHYSICAL  EXAMINATION        85 

can  be  felt  if  the  abdominal  walls  are  not  too  thick.  If  the  lower  quad- 
rant of  the  organ  can  be  clearly  palpated,  it  may  be  considered  a  movable 
kidney  (of  the  first  degree). 

Various  classifications  of  mobility  have  been  given,  some  consider- 
ing the  organ  when  palpable  in  half  its  extent,  mobility  of  second  degree; 
entirely  palpable,  mobility  of  third  degree;  and  when  descending  into  the 
abdominal  cavity,  mobility  of  fourth  degree.  Others  consider  it  movable 
if  the  entire  length  be  accessible,  especially  if  it  can  slip  down  as  far  as  the 
horizontal  umbilical  line;  and  if  it  can  be  displaced  below  this  or  across 
the  abdomen,  as  a  iloating  kidney. 

I  believe  that  any  kidney  which  can  be  palpated  to  one-fourth  of  its 
extent  should  be  considered  movable,  and  the  subdivision  into  various 
degrees  of  mobility  to  be  excellent.  A  movable  kidney  from  strain  or 
traumatism  is  comparatively  rare.    Occasionally  we  find  a  congenital 


1 


Fig.  44. — Palpation  of  kidney  (older  method). 

floating  kidney  with  no  visceroptosis.  As  a  rule,  I  believe  that  in  about 
95  per  cent,  of  cases  of  movable  kidney  the  condition  is  merely  part  of 
a  ptosis  of  the  abdominal  organs,  and  it  may  be  considered  to  be  practi- 
cally pathognomonic  of  this  condition.  The  right  kidney  is  most  frequently 
movable,  though  both  may  be  so. 

If  the  kidney  is  not  found  at  its  normal  site,  it  should  be  searched  for 
in  the  abdomen. 

In  examination  of  the  left  kidney,  the  position  of  the  hands  is  reversed. 

Method  2. — This  js,  from  personal  experience,  the  most  practical 
method  of  palpation,  and  the  varying  degrees  of  mobility  can  be  detected 
with  greater  ease  than  by  the  method  already  described. 

For  examination  of  the  right  kidney,  the  patient  sits  up  in  bed,  and 
the  left  hand  of  the  examiner  grasps  the  right  flank,  the  thumb  resting 
under  the  costal  margin,  the  fingers  posteriorly.  The  patient  breathes 
deeply,  or  coughs,  or  bears  down,  and  the  kidney  can  be  felt  to  slip 


86 


DISEASES   OF   THE    STOMACH   AND    INTESTINES 


down  between  the  thumb  and  fingers,  like  "a  pea  in  a  pod,"  or  the  lower 
margin  or  part  of  the  kidney  may  be  felt  (Fig.  45). 


Fig.  45. — Palpation  of  kidney.     Step  i. 

If  the  organ  slips  beyond  the  thumb  and  fingers  or  is  not  found  in  its 
normal  position,  then  the  left  hand  grasps  the  flank  more  firmly  and  up- 


Fig.  46, — Palpation  of  kidney.     Step  2.  Patient  in  semi-oblique  posture. 

ward  palpation  is  made  with  the  right  hand,  as  in  Fig.  46  the  patient 
gradually  assuming  the  semi-oblique,  and  finally,  the  dorsal  position,  the 
final  step,  as  shown  in  Fig.  47. 


GENERAL  METHODS  OF  PHYSICAL  EXAMINATION        87 

A  similar  method  with  the  patient  standing  was  employed  by  Goelet, 
but  the  technic  described  seems  preferable. 

For  palpation  of  the  left  kidney,  the  position  of  the  hands  is  reversed, 
the  right  hand  grasping  the  loin  and  the  left  hand  anteriorly. 

Tumors,  hydronephrosis,  and  cysts  of  the  kidney  may  be  detected  by 
palpation  of  the  abdomen,  as  already  described. 

Brewer'' s  Point. — Tenderness  at  the  costovertebral  angle  is  diagnostic 
of  an  acute  inflammatory  condition  of  the  kidney,  such  as  infarctions, 
etc.,  and  aids  in  differentiation  between  this  condition,  appendix  adherent 
to  the  liver,  and  acute  cholecystitis.  A  small  area  of  tenderness  may  be 
found  overlying  the  lowest  two  or  three  ribs^  when  that  at  Brewer's  point 
is  absent. 

Percussion  of  the  Kidney. — The  lower  and  part  of  the  outer  border 
of  the  kidney  may  at  times  be  determined  by  percussion,  comparing  the 
dulness  with  the  tympanitic  note  of  the  colon  which  lies  anteriorly.  As 
a  rule,  the  thickness  of  the  muscles,  peritoneal  fat,  or  fecal  accumulation 
renders  the  results  uncertain.     Inflation  of  the  colon  with  air  or  carbonic 


atiLTit  in  dorsal  position. 


acid  gas  may  aid  in  outlining  renal  dulness  on  percussion  by  comparison 
with  the  tympanitic  area.  A  clear  tympanitic  note  will  be  given  if  the 
kidney  is  absent  (prolapsed)  on  that  side. 

Position  for  Percussion. — The  patient  may  lie  on  the  abdomen,  with 
one  or  two  pillows  placed  underneath,  to  arch  the  back;  or  on  the  side, 
midway  between  the  lateral  and  prone  position,  the  physician  sitting  facing 
the  patient's  back  and  percussing  the  uppermost  kidney. 

One  should  commence  percussion  in  the  middle  of  the  area  in  which 
the  kidney  lies  (Fig.  43),  using  heavy  strokes,  and  percuss  outward  until 
the  kidney  dulness  is  replaced  by  tympanites;  also  percuss  downward  in 
the  same  way.  Increased  dulness  shows  enlarged  kidney.  Lerche"'^ 
holds  that,  with  the  percussion  hammer  and  ivory  plate  (plexor-pleximeter), 
and  using  a  drop  stroke  (not  tapping),  better  results  are  secured. 

To  Differentiate  a  Movable  Right  Kidney  from  the  Distended  Gall- 
bladder. — The  kidney  is  movable  in  all  directions,  can  be  carried  down- 
ward, does  not  move  with  respiration.     Tympanites  is  found  between 

^  Med.  Rcc,  July  15,  1911. 
2  Ibid.,  Feb.  4,  191 1. 


88  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

it  and  the  costal  margin;  the  shape  is  reniform,  and  it  may  be  pushed  back 
into  its  normal  position. 

The  distended  gall-bladder  moves  with  respiration,  and  can  only 
be  moved  laterally;  if  pushed  away  from  the  abdominal  wall,  it  tends  to 
resume  its  original  position,  and  there  is  no  tympanites  as  a  rule  between 
it  and  the  liver  dulness.     Occasionally  the  colon  overlaps  its  neck. 

The  chief  causes  of  enlarged  kidney  are  pyonephrosis,  perinephritic 
abscess,  hydronephrosis,  cysts,  carcinoma,  and  sarcoma. 

An  enlarged  kidney  tends  to  develop  toward  the  front;  an  abscess, 
posteriorly,  between  the  last  rib  and  the  iliac  crest. 

With  enlarged  kidney,  the  colon  overlays  in  front  of  the  tumor.  With 
splenic  tumor,  this  does  not  occur  (Fig.  40)  as  a  rule. 

If  in  doubt,  inflate  the  descending  colon  with  air  through  a  colon-tube 
or  catheter. 


PART  II 
DISEASES  OF  THE  STOMACH 


CHAPTER  V 
METHODS   OF  PHYSICAL  EXAMINATION  OF  THE   STOMACH 

General  Considerations. — For  an  intelligent  understanding  of  the 
subject,  it  is  necessary  briefly  to  define  those  conditions  which  constitute 
an  abnormality  in  the  position  of  the  stomach  and  to  differentiate 
between  them. 

The  greater  curvature  of  the  normally  distended  stomach  lies  about 
two  to  three  fingers-breadth  (1M-2K  inches)  above  the  umbilicus.  The 
normal  position  of  the  organ  has  been  indicated  in  Chapter  I.  It  must 
be  remembered  that  some  possess  an  abnormally  large  stomach,  and  that 
it  can  be  considered  to  be  dilated  only  if  there  are  symptoms  associated 
which  point  to  this  organ. 

If  there  is  atony  of  the  stomach,  with  motor  insufficiency,  the  patient 
having  gastric  symptoms,  while  the  lower  border  of  the  stomach  is  defined 
at  the  level  of  the  umbilicus  or  below  it,  the  lesser  curvature  maintain- 
ing its  relations  to  the  diaphragm,  we  rpay  consider  the  organ  to  be 
dilated.  This  constitutes  the  atonic  type  of  dilatation,  which  is  ex- 
tremely common.  Many  of  this  class  suffer  from  autointoxication  with 
nervous  sequelae,  and  are  found  in  great  numbers  in  our  asylums  and  among 
our  nervous  cases.  Attention  may  be  diverted  from  the  gastric  symptoms 
and  they  may  even  be  slight. 

As  a  result  of  pyloric  spasm,  or  benign  or  malignant  stricture  of  the 
pylorus,  or  any  obstruction  in  the  pyloric  region  interfering  with  the 
egress  of  the  gastric  contents,  we  have  the  so-called  stenotic  type  of 
dilatation  of  the  stomach. 

In  these  cases  the  lesser  curvature  retains  its  relation  to  the  diaphragm, 
while  the  lower  border  extends  to  the  umbilicus  or  below  it,  and  gastric 
symptoms  are  present  to  a  marked  degree  and  of  a  special  type. 

With  gastroptosis  (prolapse  of  the  stomach),  the  suspensory  ligaments 
of  the  stomach  are  relaxed  and  the  entire  organ  sinks,  the  lesser  curvature 
as  well  as  the  greater.  In  aggravated  cases  the  lesser  curvature  looks 
inward  to  the  right,  and  the  greater  curvature  outward  to  the  left.  The 
pylorus  may  often  lie  below  the  level  of  the  umbilicus.  With  this  condi- 
tion, movable  kidney — especially  of  the  right  organ — is  present,  and  may 
practically  be  considered  pathognomonic,  in  my  opinion,  as  only  in  about 
5  per  cent,  or  less  of  cases  is  mobility  due  to  strain  or  injury.  The  con- 
genital floating  kidney,  without  ptosis  of  other  viscera,  is  exceedingly 
rare. 

89 


90  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

There  may  be  various  degrees  of  gastroptosis,  a  loop-shape,  or  even 
a  vertical  stomach,  similar  to  that  of  the  fetal  period,  which  are  pictured 
in  the  chapter  on  Gastroptosis.  The  change  in  position  of  the  lesser 
curvature  is,  therefore,  diagnostic  of  gastroptosis,  and  not  the  position  of 
the  lower  border  of  the  stomach.  The  presence  of  movable  kidney  is  also 
diagnostic. 

It  seems  advisable  to  describe  the  methods  of  physical  examination 
generally  employed,  and  at  the  end  of  the  chapter  briefly  to  summarize 
those  which  are  of  most  practical  value. 

Preparation  of  the  Patient. — On  the  day  or  night  previous  to  examina- 
tion the  bowels  should,  if  possible,  be  thoroughly  emptied  by  a  cathartic. 
If  there  is  much  tympanites,  it  should  be  relieved  by  a  hot  enema  of  about 
I  liter  (i  quart)  of  normal  saline  solution  or  soapsuds  and  water;  or,  if  the 
condition  is  marked,  then  by  enteroclysis  at  iio°  to  i2o°F.  with  the  re- 
current tube  (Kemp's)  or  two  catheters.  This  carries  off  the  gas  in  a 
satisfactory  manner. 

The  patient  should  be  examined  in  the  dorsal,  semi-oblique,  and 
standing  positions. 

Inspection. — Examination  in  the  dorsal  position  should  first  be  made. 

A  recognizable  bulging,  distinct  from  the  epigastrium,  especially  if  it 
occur  in  the  umbihcal  or  hypogastric  region,  may  be  due  to  a  dilated 
stomach;  the  epigastrium,  under  these  conditions,  is  usually  hollow  and 
depressed.  Inspection  is  often  of  assistance  in  thin  patients,  especially 
after  artificial  distention  of  the  stomach  with  carbonic  acid  gas. 

Peristaltic  movements  of  the  dilated  stomach  are  at  times  observed. 

Kiissmaul  has  noted  very  active  peristaltic  movements  in  the  dilated 
stomach  (peristaltic  unrest),  the  waves  passing  from  the  linea  alba  below 
the  umbilicus  in  an  upward  direction  and  to  the  right  to  the  lower  margin 
of  the  liver.  This  is  found  present  in  cases  in  which  stenosis  of  the 
pylorus  exists. 

We  can  facilitate  inspection  by  placing  the  patient  upon  a  raised  table, 
the  head  toward  the  window,  the  shades  being  arranged  so  that  the  light 
enters  on  a  plane  only  slightly  above  that  of  the  patient,  and  is  directed 
from  the  head  toward  the  feet.  The  examiner,  standing  toward  the  foot 
of  the  table  and  bending  from  side  to  side,  can  at  times  make  out  shadows 
cast  by  the  inequalities  of  the  abdomen.  The  shadows  move  with 
respiration.  By  this  method  the  size,  shape,  and  position  of  the  stomach 
can  often  be  made  out. 

Knapp  places  the  patient  in  the  same  position,  but  stands  at  the  side 
or  at  the  shoulders,  and  brings  his  eyes  down  to  the  level  of  the  abdomen 
and  observes  the  respiratory  waves  passing  over  its  surface.  After  some 
experience  one  can  detect  delicate  transverse  lines  or  waves  passing 
upward  and  downward  with  respiration.  These  lines  correspond  to  the 
curvatures  of  the  stomach. 

More  recently  he  places  the  patient  facing  a  good  light,  and,  stand- 
ing slightly  to  the  side,  observes  the  movements  of  the  transverse  lines. 
I  have  seen  good  results  from  this  method,  especially  for  detemination 
of  the  lower  border  of  the  stomach. 

The  following  signs  I  have  found  quite  reliable:     With  the  patient 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH  91 

in  the  recumbent  position,  a  marked  concavity  between  the  costal  arches 
— extending  from  the  ensiform  process  to  or  below  the  umbiUcus,  with  a 
vertical  median  sulcus,  wider  above  than  below,  the  abdomen  being 
flattened  in  the  central  part  and  bulging  in  the  lateral  regions — is  signifi- 
cant of  gastroptosis.  In  the  erect  position  the  epigastrium  becomes  stll 
more  depressed,  while  the  umbilical  and  especially  the  pubic  regions  bulge 
outward.  Tumors  of  the  stomach  may  sometimes  be  observed,  causing 
slight  projection  or  protuberance  on  the  abdominal  wall. 

Palpation  of  the  Stomach. — Inspection  should  be  supplemented  by 
palpation.  Palpation  should  be  performed  gently,  and  the  hands  of  the 
operator  should  be  warm. 

The  patient  should  be  in  the  dorsal  position,  with  the  legs  flexed,  to 
relax  the  abdominal  muscles.  He  should  breathe  naturally  and  keep  the 
mouth  open  to  aid  relaxation.  The  physician  should  be  seated  on  the 
right  side  of  the  bed  and  palpate  with  the  right  hand,  which  should  be 
flat  or  slightly  bent  upon  the  abdomen,  with  the  ulnar  side  down.  One 
can  stroke  from  above  downward,  and  with  practice  it  is  possible,  in  some 
cases,  to  feel  the  stomach-wall  and  appreciate  the  position  of  the  greater 
curvature,  as  the  stomach  gives  a  more  uniform  elastic  sensation  than  do 
the  intestinal  walls.  Some  commence  palpation  from  below  and  work 
upward,  dipping  in  the  ulnar  edge  of  the  hand  rather  deeply.  By  these 
means  it  is  at  times  possible  to  determine  the  position  of  the  greater 
curvature. 

By  palpation  we  can  discover  if  nephroptosis  is  present.  Diastasis 
of  the  recti  muscles  and  floating  tenth  rib  can  also  be  determined.  These 
conditions  are  significant  of  gastroptosis.  Under  inspection  I  have  noted 
the  signs  that  are  significant  of  gastroptosis.  If  we  find  a  "movable 
kidney,"  this  renders  our  diagnosis  conclusive. 

By  gentle  palpation  one  can  frequently  discover  a  tumor,  its  position, 
size,  consistency,  and  mobility.  Occasionally,  more  pressure  is  necessary, 
and  the  palpating  hand  may  be  reinforced  by  the  other  hand,  after  the 
method  described.     (See  Fig.  28.) 

Sensitive  or  tender  points  can  be  located  by  palpation;  for  example, 
the  circumscribed  tenderness  of  an  ulcer,  or  the  diffuse  tenderness  of  the 
gastric  region  in  acute  inflammation.  Boas  has  devised  an  algesimeter 
for  indicating  the  degree  of  pain.  T.  Kilmer  has  also  an  instrument  for 
the  same  purpose. 

Considerable  care  should  be  exercised  in  palpation  in  cases  of  sus- 
pected ulcer,  and  I  prefer  the  hand  for  this  purpose. 

Percussion  of  tiie  Stomach. — The  accurate  determination  of  the 
position  and  size  of  the  stomach  is  often  difficult  by  simple  percussion. 
The  sound  varies,  according  to  whether  the  organ  is  empty  or  fiUed  with 
air,  food,  and  water. 

The  position  of  the  patient,  whether  lying  down,  semi-oblique,  or 
standing,  modifies  the  findings.  In  order  to  obtain  results,  the  stomach 
should  contain  some  air.  Dehio  has  demonstrated,  both  on  living  subjects 
and  on  the  cadaver,  that  if  the  stomach  is  empty,  the  tympanitic  sound 
which  we  produce  on  percussion  is  due  to  the  colon  and  not  to  the  stomach, 
since  the  latter  is  contracted  into  the  left  concavity  of  the  diaphragm  and 


92  DISEASES    OF    THE    STOMACH    AXD    INTESTINES 

is  not  in  contact  with  the  anterior  thoracic  wall.  Hence  the  time  at  which 
the  examination  is  made  is  important.  Moreover^  the  lower  curvature 
tends  to  fall  away  from  the  abdominal  wall. 

The  patient  should  first  be  examined  in  the  dorsal  position  with  the 
knees  flexed. 

This  method  determines  with  fair  accuracy  the  upper  right  and  upper 
left  portions.  The  percussion  hammer  is  sometimes  an  aid.  The  ab- 
solute determination  of  the  lower  border  by  percussion  is  more  difficult. 
It  is  rendered  easier  if  the  bowels  have  been  thoroughly  emptied,  since 
the  colon  is  then  less  likely  to  ride  over  the  greater  curvature.  The  per- 
cussion sound  over  the  colon  is  lighter  and  does  not  equal  that  over  the 
stomach.  The  stomach  sound  is  of  greater  intensity  and  clearness  and  of 
higher  pitch.  This,  of  course,  refers  to  conditions  when  air  is  present  as 
the  factor.  Food  or  fecal  contents  alter  the  result,  which  is  further  modi- 
fied by  percussion  in  the  semi-oblique  and  standing  positions. 

As  a  rule,  there  are  some  contents  in  the  transverse  colon,  so  that  we 
have  the  tympanites  of  the  stomach  merging  into  dulness  or  flatness. 
With  gastroptosis,  determination  of  the  position  of  the  organ  by  simple 
percussion  is  often  difficult. 

The  presence  of  a  tumor  can  frequently  be  determined  by  percussion. 

Dorsal  Gastric  Xucleus  of  Resonance. — William  Ewart,  in  his  com- 
munication in  the  Proceedings  of  the  Royal  Society  of  Medicine, 
July,  i9io,.has  contributed  a  new  method  of  post-gastric  percussion,  and 
has  described  a  hitherto  unrecognized  ''dorsal  gastric  nucleus  of  reso- 
nance." This  consists  of  a  circular  area,  from  2  to  2}^  inches  in  diameter, 
situated  immediately  below  the  inferior  angle  of  the  left  scapula.  Over 
this  area  the  percussion-note  is  one  of  increased  resonance  and  of  a  tym- 
panitic quality.  This  is  the  result  of  the  deep-seated  resonance  of  the 
stomach,  the  constancy  of  its  position  and  its  circular  shape  being  deter- 
mined by  sound  refraction,  the  liver  acting  as  a  lens  for  the  resonant  waves. 
The  clinical  value  of  this  sign  is  concerned  chiefly  with  the  diagnosis  of 
the  various  forms  of  dilatation  of  the  stomach.  The  loss  of  perfectly 
circular  outline  is  the  first  step  toward  the  disappearance  of  the  gastric 
nucleus,  which  may  be  the  starting-point  of  progressive  encroachment 
outward  of  an  enlarging  area  of  dorsal  gastric  resonance.  This  is  the  dorsal 
or  backward  type  of  upward  dilatation  of  the  stomach  which  was  first 
definitely  described  by  Ewart,  who  believes  this  to  be  the  cause  of  one  of 
the  most  severe  and  dangerous  forms  of  heart  distress  of  mechanical  gastric 
origin. 

Auscultatory  Percussion. — With  this  method  we  employ  the  stetho- 
scope. The  chest-piece  may  be  placed  above  the  seventh  rib  in  the  left 
mammillary  line,  or  between  the  tip  of  the  ensiform  process  and  the 
left  costal  margin;  or  in  the  same  vertical  line,  but  slightly  below  these 
points.  First  percuss  near  the  stethoscope  to  fix  the  characteristic  sound. 
The  tympanites  of  the  stomach  is  transmitted  generally  through  the  liver 
and  lung.  The  percussion  should  be  begun  well  distant  from  the  possible 
location  of  the  stomach,  and  should  be  performed  in  the  vertical  direction, 
downward,  upward,  and  also  laterally.  One  should  begin  nearly  at  the 
symphysis  and  percuss  in  vertical  lines  upward  (Fig.  48). 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH 


93 


The  patient  should  be  in  the  usual  position,  as  described,  and  should 
hold  the  stethoscope  for  the  operator  against  the  abdomen.     A  sound  of 


Fig.  48.-^ Vertical  lines  of  auscultatory  percussion.     Circles  show  positions  of 

stethoscope. 

greater  intensity  and  clearness  and  of  higher  pitch  denotes  the  border 
of  the  stomach.  The  greater  bulk  of  the  organ,  when  dilated  or  in  a 
condition  of  ptosis,  lies  to  the  left  of  the  median  line.     We  must  remember 


Fig.  49. — Auscultatory  percussion  of  tumor  of  stomach  wall. 


that  some  cases  of  marked  dilatation  extend  a  great  distance  to  the  right 
of  the  abdomen. 

This  method  is  of  value  in  determination  of  a  tumor  of  the  stomach. 


94  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Place  the  stethoscope  at  0,  Fig.  49,  and  percuss  toward  the  tumor 
from  all  directions.  The  sound  heard  over  the  tumor  (C)  differs  in  char- 
acter from  that  heard  over  the  stomach  at  D.  If  the  growth  involves  the 
stomach  wall,  C  resembles  D  much  more  nearly  than  A  (percussion  of 
liver)  and  B  (percussion  of  intestines)  resembles  D  (stomach  percussion). 

Differential  Diagnosis. — If  a  tumor  hes  at  D,  near  the  margin  of  the 
liver  (Fig.  50),  tumor  of  the  hver  is  excluded  as  follows:  place  stethoscope 
at  S,  over  liver.  Percussion  note  over  D  resembles  note  over  G  more  than 
it  resembles  that  over  F.  Then  to  exclude  intestines,  shift  stethoscope 
to  K,  over  stomach.  Percussion  over  D  resembles  that  over  M  more  closely 
than  that  over  G  resembles  that  over  M.  The  tumor  is,  therefore,  of  the 
stomach. 


Fig.  50. — Differential  diagnosis. 

Reichmann's  Rod. — This  consists  of  a  short  ivory  rod,  with  circular 
grooves  and  intervening  projections,  like  the  handle  of  an  ivory  knitting- 
needle.  The  rod  is  pushed  firmly  down  over  the  stomach  at  a  right  angle 
to  its  surface  (in  a  vertical  line  to  the  abdomen),  and  is  gently  stroked 
with  the  finger.  The  stethoscope  is  applied  over  the  organ  and  the 
"pitch"  carefully  observed.  When  the  rod  passes  beyond  the  limits  of 
the  stomach,  a  change  in  "pitch"  occurs. 

Scratch  Method  of  Auscultatory  Percussion. — This  method  I  have 
found  satisfactory  in  many  cases. 

The  stethoscope  is  placed  on  the  abdomen  below  the  left  border  of 
the  ribs,  and  with  the  index-finger  of  the  right  hand  the  abdominal  wall  is 
scratched  gently  by  the  examiner  so  as  to  secure  the  "normal  pitch" 
over  the  stomach.  The  abdomen  is  then  scratched  lightly  from  above 
downward  and  also  from  below  upward,  commencing  below  the  umbilicus, 
and  the  change  in  "pitch"  is  readily  observed  when  the  lower  border  of  the 
stomach  is  reached. 

If  gastroptosis  is  believed  to  exist,  the  stethoscope  is  placed  more  to 
the  left,  and  the  "scratch  pitch"  noted  from  left  to  right.     The  method 


METHODS    OF    PHYSICAL   EXAMINATION    OF    THE    STOMACH  95 

is  shown  in  Fig.  51.  It  is  of  special  value  in  determining  the  lower  border 
of  the  stomach. 

Flicking. — This  method  was  described  and  illustrated  in  the  previous 
chapter. 

Inflation  of  the  Stomach  with  Carbonic  Acid  Gas. — Carbonic  acid 
gas  inflation  is  employed  to  render  the  stomach  visible  to  inspection; 
to  aid  the  determination  of  the  position  of  the  lesser  curvature,  as  well  as 
the  greater,  and  so  enable  a  differential  diagnosis  between  dilatation  and 
gastroptosis. 

The  method  is  to  administer,  first,  one  glass  of  water  in  which  about 
I  dram  of  tartaric  acid  is  dissolved,  and,  after  this,  one  glass  of  water 


Fig.  51. — "Scratch  method"  of  auscultatory  percussion. 

containing  from  1  to  i^^  drams  of  soda  bicarbonate.  If  small  quantities 
are  employed,  the  stomach  will  not  become  visible  and  palpable. 

There  are  certain  objections  to  this  procedure.  At  times  there  is 
considerable  escape  of  gas  through  the  cardiac  orifice  or  pylorus  and  the 
small  intestine  may  be  distended.  This  is  a  possible  source  of  error. 
There  may  be  sudden  hyperdistention  of  the  stomach,  with  resulting  pres- 
sure on  the  heart  and  lungs,  and  unpleasant  or  even  dangerous  symptoms 
result  in  the  aged  or  in  a  patient  suffering  from  cardiac  or  pulmonary 
disease.  In  the  chapter  on  Acute  Dilatation  of  the  Stomach  the  effects 
of  sudden  distention  of  the  stomach  on  the  heart  and  circulation  are 
described  by  Thomas  Satterthwaite  and  the  author. 

When  there  has  been  a  recent  hemorrhage  from  ulcer  or  cancer,  or 
signs  of  peritonitis,  the  use  of  this  method  is  contraindicated.  Several 
fatal  accidents  have  occurred.     It  sometimes  irritates  the  mucous  mem- 


96  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

brane.  One  could  employ  a  stomach-tube  and  Dr.  Rose's  carbonic  acid 
gas  generating-bottle  as  a  substitute.  Carbonic  acid  gas  inflation  is 
valuable  in  those  who  are  in  fair  physical  condition. 

In  the  determination  of  the  position  of  a  tumor,  whether  it  lies  on  the 
anterior  or  posterior  surface  of  the  stomach,  inflation  with  carbonic  acid 
gas  is  of  service.  A  posterior  tumor  will  disappear  under  inflation.  This 
is  fully  described  under  Cancer  of  the  Stomach. 

Inflation  of  the  Stomach  with  Air. — This  consists  in  introducing  a  soft 
stomach-tube  and  slowly  pumping  air  into  the  stomach  with  a  double- 
bulb  or  a  Davidson  syringe.  The  tube  should  be  introduced  with  the 
patient  sitting  up  in  bed,  and  he  should  then  gently  recline  on  the  back  and 
inflation  should  be  carried  out.  It  possesses  the  advantage  that  the 
amount  of  air  pumped  into  the  stomach  can  definitely  be  regulated. 
Fill  a  vessel  with  i  liter  (i  quart)  of  water,  invert  it  over  a  pail  of  water, 
and  note  how  many  compressions  of  the  bulb  displace  the  given  quantity 
of  fluid.  One  can  thus  estimate  the  quantity  of  air  pumped  in  at  each 
compression.  The  first  few  squeezes  of  the  bulb  should  be  given  rapidly, 
so  as  to  cause  spasmodic  closure  of  the  pylorus. 

The  same  indications  and  contraindications  exist  as  for  the  use  of 
carbonic  acid  gas.  There  is  the  advantage  of  being  able  to  regulate  more 
definitely  the  degree  of  inflation.  Some  patients,  however,  object  to 
the  passage  of  the  tube.  If  there  are  discomfort  or  unpleasant  symptoms 
from  either  method  of  inflation,  the  condition  should  be  immediately 
relieved  by  the  passage  of  the  stomach-tube. 

Fiirbringer  suggests  that  when  we  inflate  with  air  the  tube  should  be 
introduced  only  to  the  middle  of  the  esophagus,  and  air  should  then  be 
pumped  in.     He  claims  that  this  procedure  prevents  retching. 

Inflation  of  the  Stomach  with  Water. — To  Dehio  we  must  give  the 
credit  of  determining  the  position  of  the  stomach  by  water  inflation. 
He  percusses  over  the  patient's  stomach,  preferably  with  the  organ  empty 
and  the  patient  in  the  erect  position.  He  then  administers  a  glass  of 
water  (8  ounces),  not  too  cold,  and  percusses  the  area  of  the  dulness. 
He  follows  this  with  a  second,  third,  and  fourth  glass  of  water,  percussing 
each  time,  and  notes  the  position  and  extent  of  the  dulness.  The  patient 
is  then  directed  to  lie  on  his  back,  and  tympanites  will  appear  where  dul- 
ness previously  existed.  This  conclusively  demonstrates  that  the  area 
corresponded  to  the  stomach. 

If  there  is  pronounced  dilatation  or  ptosis,  a  single  glass  of  water  will 
often  cause  dulness  to  appear  below  the  navel  or  in  the  inguinal  region. 
The  results  may  be  obscured  in  patients  with  much  adipose  tissue  or  if  there 
is  fecal  accumulation  in  the  colon.  In  this  last  event,  it  should  be  cleared 
out  by  injection.  I  have  also  found  the  following  method  of  value,  es- 
pecially if  there  be  some  gastric  contents:  first,  place  the  patient  in  the 
semi-oblique  position  and  percuss  the  stomach;  then  administer  two  or  even 
three  glasses  of  water.  We  secure  stomach  tympanites  above,  then  a  band 
of  stomach  dulness,  and  intestinal  tympanites  below.  It  is  easier  to 
differentiate  between  dulness  and  tympanites  than  between  two  types  of 
tympanites. 

There  are  numerous  complicated  methods  by  means  of  inflatable  bags, 


METHODS    OF   PHYSICAL   EXAMINATION   OF   THE  STOMACH  97 

manometers,  etc.,  for  determining  the  position  of  the  stomach  which  are 
scarcely  of  practical  value.  Leube  introduces  a  stiff  sound  and  determines 
the  position  of  its  lower  end  through  the  abdominal  walls.  This  method 
does  not  seem  to  be  safe.  Others  differentiate  between  the  stomach  and 
the  colon  by  inflating  the  colon  with  air  or  carbonic  acid,  employing  the 
same  methods  as  in  the  stomach,  only  using  twice  the  quantity  of  soda 
bicarbonate  and  tartaric  acid.  Rose's  apparatus  would  prove  of  value 
to  inflate  the  bowel.  To  further  differentiate,  water  was  given  by  the 
stomach.  Some  first  empty  the  bowel  thoroughly  and  then  inflate  the 
intestine  with  water.  It  is  often  difficult  for  the  patient  to  hold  the 
enema. 

There  are  two  other  methods  for  determining  the  lower  margin  of 
the  stomach:  First,  the  administration  of  small  quantities  of  soda  bi- 
carbonate and  tartaric  acid,  with  the  patient  in  the  standing  position. 
In  some  cases  one  can  approximately  map  out  the  lower  border  of  the 
stomach  by  listening  to  the  "sizzling  sounds"  with  the  stethoscope. 
Second,  the  use  of  the  stomach-whistle  (Fig.  52).  This  consists  of  a  rectal 
tube  of  small  caliber,  with  a  whistle  in  the  end.  To  the  other  extremity 
is  attached  an  ordinary  stomach  aspirating  bulb  without  valves.     The 


Fig.  52. — Kemp's  stomach-whistle. 

tube  is  inserted  into  the  stomach,  the  firiger  placed  over  the  open  end  of 
the  bulb,  and  a  single  bulbful  of  air  is  forced  into  and  aspirated  out  of  the 
stomach  by  rapid  and  short  intermittent  contractions.  This  entirely 
eliminates  the  possible  chance  of  distending  the  stomach  with  air,  and  the 
organ  remains  practically  empty. 

A  stethoscope  is  placed  over  the  abdomen  and  the  point  of  greatest 
intensity  of  sound  is  marked  by  a  cross  with  a  colored  pencil.  The  tube 
is  pushed  in  and  out  and  the  various  points  of  sound  are  marked — the 
lowest  is  in  the  lower  border  of  the  stomach.  The  ear  can  be  applied  in 
place  of  the  stethoscope.  Transillumination  of  the  organ  was  then 
performed  and  the  lower  margins  absolutely  corresponded.  The  method 
of  administering  water  and  then  blowing  air  into  the  stomach  through  a 
tube,  and  producing  "bubbling  sounds,"  only  gives  the  level  of  the  fluid, 
and  not  accurately  the  lower  margin  of  the  stomach.  The  whistle  will 
not  differentiate  between  dilatation  and  gastroptosis.  This  experiment 
with  the  stomach-whistle  demonstrated  that  in  the  standing  position 
the  stomach,  when  empty,  descends  to  the  full  length  of  its  suspensory 
ligaments,  and  its  lower  border  is  at  a  constant  level  or  within  about  i 
inch  of  the  same,  whether  the  organ  be  full  or  empty.  The  stomach- 
whistle  was  described  as  early  as  1892  by  Spivak,  of  Denver,  for  the 
7 


98 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


purpose  of  measuring  the  esophagus,  and  S.  J.  Meltzer  previously  experi- 
mented with  an  instrument  devised  on  the  same  principle.  The  writer 
does  not  recommend  the  whistle,  but  merely  recounts  its  use  as  a  matter 
of  interest. 

Splashing  Sounds. — The  splashing  sounds  of  the  stomach  are  pro- 
duced when  water  and  air  in  the  organ  are  agitated  together,  when  either 
the  whole  body  or  the  stomach  alone  is  shaken.  They  are  best  demon- 
strated by  rapidly  tapping  with  the  index-  and  middle  fingers  of  the  right 
hand  over  the  stomach  several  times  in  succession  without  removing 
the  fingers,  as  in  striking  chords  on  the  piano.  The  patient  should  be  in 
the  dorsal  position,  with  the  lower  limbs  flexed. 

The  sounds  resemble  those  produced  by  shaking  a  rubber  bag  con- 
taining air  and  water. 

They  can  be  elicited  in  many  people  in  ordinary  good  health  shortly 
after  meals,  but  if  found  at  an  abnormal  time  or  in  an  abnormal  position, 
are  of  diagnostic  value.  If  present  an  hour  after 
a  test-breakfast,  the  patient  suflFering  from  gas- 
tric symptoms  and  the  position  of  the  stomach 
being  normal,  they  are  significant  of  simple 
atony.  This  is  true  if  they  be  found  several 
hours  after  an  ordinary  meal  or  on  an  empty 
stomach.  If  the  splash  is  present  in  an  abnor- 
mal position  at  the  level  or  below  the  umbilicus, 
it  shows  the  lower  border  of  the  stomach  lies 
abnormally  low,  and  that  either  dilatation  or 
gastroptosis  is  present. 

The  presence  of  movable  kidney  demon- 
strates it  is  a  ptosis.  The  upper  border  may  be 
determined  to  be  in  an  abnormal  position  by 
inflation  or  gastrodiaphany,  as  a  further  test. 

The  splashing  sound  determines  the  position 
of  the  lower  border  of  the  stomach  with  greater 
accuracy  than  percussion.  Some  patients  hold 
the  abdomen  rigid,  so  that  it  does  not  appear  on  examination,  but  it  can 
be  produced  artificially  for  examination  purposes. 

The  following  is  a  simple  method  to  differentiate  between  stomach 
and  intestinal  splash: 

In  Fig.  53,  if  the  splash  be  found  at  A,  mark  same  on  the  abdominal 
wall;  then  give  several  glasses  of  water  or,  preferably,  Vichy.  If  the 
splash  at  A  be  intensified,  it  is  stomach  splash.  If,  on  the  other  hand, 
the  splash  appear  at  B,  this  is  the  true  stomach  splash  and  A  is  the  in- 
testinal splash. 

If  no  splash  is  present  on  examination,  it  can  be  created  artificially 
by  giving  several  glasses  of  water  or  small  quantities  of  soda  bicarb,  and 
tartaric  acid  in  a  glass  of  water  or,  preferably,  Vichy.  Sometimes  three 
or  four  glasses  of  water  are  required;  the  patient  takes  several  deep 
breaths,  the  splash  being  determined  during  expiration.  I  find  the 
determination  of  the  lower  border  of  the  stomach  most  accurate  by  means 
of  the  splashing  sound. 


Fig.  S3.— Splashing 
sound.  Dififerential  diag- 
nosis between  stomach 
and  intestinal  splash. 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH  99 

Deglutition  Sounds. — These  were  first  described  by  Kronicker  and 
Meltzer.^ 

When  drinking,  a  sound  is  heard  simultaneously  with  the  act  of 
deglutition,  which  is  termed  the  first  deglutition  sound.  A  second  sound 
is  noted  about  seven  seconds  later.  Both  sounds  can  be  heard  by  plac- 
ing the  ear  or  stethoscope  at  the  ensiform  process.  As  a  rule,  only  the 
second  sound  is  heard.  If  the  first  sound  is  heard,  the  second  may  be 
present  or  absent.  The  presence  of  these  sounds  assists  in  forming  judg- 
ment as  to  the  permeability  of  the  cardiac  orifice.  If  they  are  absent, 
the  ingested  liquid  has  remained  in  the  esophagus,  and  hence  a  tight 
stricture  is  present.  If  the  second  sound  is  markedly  delayed,  there  is 
probably  partial  obstruction. 

Other  Sounds  have  been  Described. — Dripping  sounds,  arising 
from  the  passage  of  fluid  along  the  gastric  wall,  are  suggested  as  a  means 
of  mapping  out  the  stomach.     The  method  is  inaccurate. 

The  succussion  sound,  obtained  by  shaking  the  body  of  the  patient, 
is  not  as  accurate  a  method  as  by  tapping. 

Gurgling  sounds  occur  from  the  contraction  of  the  empty  stomach 
about  air  or  gas.  Sounds  are  heard  in  the  stomach  due  to  movements 
imparted  to  the  organ  through  the  respiration,  and  also  ringing  sounds, 
imparted  from  the  heart  in  gastric  dilatation.^ 

These  sounds  are  of  no  diagnostic  value.  Occasionally  sizzling 
sounds  are  heard  on  auscultation,  which  are  produced  by  fermentation 
of  the  gastric  contents.  They  resemble  the  sounds  produced  after 
the  administration  of  soda  bicarbonate  and  tartaric  acid,  with  the  re- 
sulting generation  of  carbonic  acid  gas. 

Esophagoscopy. — Mikulicz,  Rosenheim,  Kelling,  von  Hacker,^  Ein- 
horn,^  and  many  others  have  advocated  this  method. 


~     Fig.  54. — Einhorn's  esophagoscope. 

In  the  earlier  instruments  the  source  of  illumination  was  outside 
the  esophageal  tube.  The  instrument  with  the  lamp  at  the  end  of 
the  tube  near  the  point  to  be  inspected,  such  as  devised  by  Einhorn, 
is  more  practical. 

^  Centralbl.  f.  die  med.  Wissenscli.,  1883,  No.  i. 

^  Laker,  Wiener  med.  Presse,  1889,  Nos.  43  and  44. 

'  Beitrage  zur  klinischen  Chir.,  Bd.  20,  1898,  pp.  141,  275;  Ibid.,  Bd.  29,  i90i,p.  128. 

*  New  York  Med.  Jour.,  Dec.  11,  1897. 


lOO 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


In  Fig.  54  is  depicted  his  instrument,  which  is  readily  understood. 

The  obturator  is  inserted  and  held  in  place  by  the  plug  d  and  the 
wires  connected  with  the  battery. 

After  introduction,  the  plug  is  removed,  the  obturator  withdrawn, 
and  the  current  turned  on. 


Fig.  55- — Misleading  schema  of   direct   bronchoscopy.     Same   position   improper  in 
esophagoscopy  (Chevalier  Jackson). 


Technic. — The  pharynx  should  be  sprayed  with  cocain  (4  per  cent.) 
or  eucain  (5  per  cent).  The  patifent  sits  on  a  chair  with  a  straight  back. 
The  instrument  with  obturator  inserted  is  immersed  in  warm  water,  and 
inserted  like  a  pen  along  the  roof  of  the  mouth  to  the  posterior  wall  of  the 
pharynx,  the  head  being  thrown  backward  on  the  shoulders,  but  not  in 


Fig.  56. — Schema  showing  correct  position  of  patient  and  of  the  instrument  in 
relation  to  the  air-passages.  The  instrument  should  touch  the  upper  teeth  very 
gently,  if  at  all.     This  is  also  the  proper  position  for  esophagoscopy  (Chevalier  Jackson). 

too  forced  extension.  The  tube  should  be  lubricated  with  olive  oil  or 
white  vaseline  if  difficult  to  pass.  The  tube  is  then  pushed  down  in  a 
vertical  line  into  the  esophagus  without  the  exertion  of  any  force.  By 
this  method  it  is  unnecessary  to  press  down  on  the  tongue,  and  thus 
gagging  is  avoided. 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH 


lOI 


The  lips  of  the  patient  should  not  be  pressed  upon  by  the  instru- 
ment. The  obturator  is  removed,  the  light  turned  on,  and  the  eye 
of  the  operator  applied  to  the  opening. 


Fig. 


-Correct  position  of  the  cervical  spine  for  esophagosco{)y  and  bronchoscopy. 
Radiograph  by  T)r.  (ieorge  C.  Johnston  (Chevalier  Jackson). 


Fig.  58. — Curved  position  of  the  cervical  spine  in  the  Roser  position,  rendering 
esophagoscopy  and  bronchoscopy  difficult  or  impossible.  The  devious  course  of  the 
pharynx,  larynx,  and  trachea  are  plainly  visible.  Radiograph  by  Dr.  George  C. 
Johnston  (Chevalier  Jackson). 


For  complete  inspection  of  the  esophagus,  the  instrument  is  gradually 
withdrawn. 


I02  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

This  esophagoscope  is  made  in  several  lengths  and  in  two  sizes. 

Lewisohn  has  devised  a  rectangular  telescopic  esophagoscope,  which 
can  be  introduced  in  the  normal  position  of  the  head.  It  possesses  the 
disadvantage  of  being  complicated,  gives  indirect  vision,  is  more  difficult 
to  keep  free  from  mucus  and  instrumentation  through  it  is  practically 
impossible.      It  is  of  chief  value  for  inspection. 

Chevalier  Jackson^  has  devised  an  improved  esophagoscope  which 
contains  an  auxiliary  tube  for  drainage  and  suction  of  the  secretions. 
For  esophagoscopy  frequently  the  upright  position  can  be  employed, 
though  in  some  cases  the  dorsal  position  is  preferable.  Fig.  55  is  the 
incorrect  position.  In  Fig.  56  Jackson  shows  the  correct  position  of 
the  head  when  bronchoscopy  is  performed  in  the  upright  position.  The 
posture  is  the  same  in  esophagoscopy.  In  Figs.  57  and  58  are  shown  the 
correct  and  incorrect  positions  for  esophagoscopy  in  the  dorsal  position. 

In  the  dorsal  recumbent  position,  the  head  should  be  squarely  ex- 
tended on  the  occipito-atlantal  joint,  not  on  the  cervical  spine.  If  the 
head  is  held  in  the  position  of  Roser,  the  cervical  vertebrae  are  curved, 


Fig.  59.  Fig.  60. 

Fig.  59. — -Schema  showing  relation  of  the  cricoid  cartilage  (the  circle)  to  the  pos- 
terior hypopharyngeal  wall,  in  the  dorsally  recumbent  patient,  observer  looking  down 
the  esophagus.     The  pyriform  sinuses  are  at  the  position  marked  X . 

Fig.  60. — Thimble  gag  or  bite  block  for  bronchoscopy  and  esophagoscopy  (Jackson). 

and  the  esophagoscope  abuts  almost  vertically  on  the  convexity  and  can- 
not be  introduced  within  the  introitus  esophagi,  according  to  Jackson 
(Fig.  58).    ^  ^  •  _  ^ 

The  assistant  is  placed  on  the  right  side  of  the  patient's  head,  on  a 
stool  of  appropriate  length,  as  though  on  a  side  saddle,  his  right  leg 
beneath  him  in  the  kneeling  position,  his  left  foot  supported  on  a  stool 
26  inches  lower  than  the  top  of  the  table.  His  right  forearm  is  passed 
beneath  the  patient's  neck,  supporting  it;  his  right  hand  holds  the  mouth- 
gag,  drawing  it  strongly  at,  or  in  front  of,  the  bregma,  bending  it  back- 
ward and  exerting  a  certain  degree  of  upward  pressure.  The  mouth-gag 
is  inserted  on  the  left  side.  The  patient  should  have  the  tops  of  the 
shoulders  clear  of  the  table  by  from  4  to  6  inches. 

If  an  attempt  is  made  to  pass  the  esophagoscope  in  the  middle  line, 
it  encounters  the  cricoid  cartilage.  It  should  be  inserted  into  the  pyriform 
sinus  (Fig.  59),  preferably  the  right  one,  and  thence  into  the  esophagus. 
A  bite  block,  preferably  Boyce's  (Fig.  60),  should  be  used  in  preference 
to  a  mouth-gag — the  so-called  thimble  gag.  Jackson's  armamentarium 
for  esophagoscopy  consists  of  the  following  instruments: 

^  Jour.  .\mer.  Med.  Assoc,  Sept.  25,  1909. 


METHODS    OF    PHYSICAL   EXAMINATION    OF   THE    STOMACH 


103 


esophagoscope  (10  mm.  by  53  cm.)  for  adults. 

esophagoscope  (7  mm.  by  45  cm.)  for  children. 

adult's  slide  speculum. 

child's  sUde  speculum. 

aspirator  for  the  esophagoscope,  to  remove  secretions. 

specimen  forceps,  long  and  short  (Fig.  61). 


Fig.  61. — Specimen  forceps  tip  to  fit  universal  handle.  The  side  jaw  will  bite 
into  a  flat  lateral  wall.  The  cross  forms  the  bottom  of  a  basket  to  hold  the  tissue 
removed. 

I  foreign  body  forceps. 

3  Coolidge  sponge-holders. 

In  esophagoscopy  for  foreign  bodies,  the  tube  should  be  introduced 
without  the  mandrin,  and  every  part  be  explored  during  its  introduction. 
This  avoids  the  danger  of  overriding  the  foreign  body.     The  safest  cur- 


Fig.  62. — Brunning's  modification  of  Killian's  esophagoscope  (Plummer). 

rent  for  the  light  is  a  double  dry  battery,  two  sets  of  four  cells  each,  in 
case  one  fails.  Each  set  should  have  two  binding  posts  and  a  rheostat. 
Ingalls  holds  that  rheostats  devised  for  adapting  commercial  circuits  to 
tube  work  are  dangerous  when  attached  to  a  tube  which  makes  a  moist 
contact  with  tissues  close  to  the  course  of  the  vagi.     It  is  preferable,  when 


I04 


DISEASES    OF   THE    STOMACH    AND   INTESTINES 


possible,  to  determine  the  position  of  a  foreign  body  in  the  esophagus  by 
a  radiograph  before  attempted  removal  through  the  esophagoscope. 
Both  lateral  and  anteroposterior  radiographs  should  be  taken,  as  the  foreign 
body  may  show  in  one  and  not  in  the  other. 

Plummer^  recommends  Brunning's  modification  of  Killian's  esophago- 
scope (Fig.  62),  as  it  has  a  tip  well  adapted  for  easily  passing  the  cricoid. 
Occasionally,  a  guide  may  be  necessary,  after  the  methods  already 
described  under  Stenosis  of  the  Esophagus. 

Lerche^  has  devised  an  ingenious  instrument  for  closing  an  open 
safety-pin  impacted  in  the  esophagus,  and  removing  the  same  through 
the  esophagoscope  (Fig.  63). 

Indications. — Esophagoscopy  is  of  chief  value  as  an  aid  for  the  removal 
of  foreign  bodies.  It  may  be  employed  for  inspection  of  suspected  ulcera- 
tion and  for  topical  application  through  the  esophagoscope  or  to  remove 
through  it  a  small  section  of  a  tumor.  In  suspected  cancer  it  should  be 
used  with  caution. 


Fig.  63.- 


-Instrument  devised  for  closing  open  safety-pin  and  directing  it  through 
gastroscope  (Lerche). 


Contraindications. — Aneurysm  or  recent  hemorrhage. 

Gastroscopy. — This  method  of  examination  of  the  gastric  mucosa  was 
inaugurated  by  Mikulicz  in  1881.^ 

The  general  principle  of  the  instrument  is  based  on  the  cystoscope. 
Rosenheim  has  devised  a  new  instrument,  and  Chevalier  Jackson  has 
carried  on  numerous  investigations  with  gastroscopy.  The  latter  has 
conclusively  demonstrated  that  general  anesthesia  should  be  given  for 
such  an  examination. 

Chevalier  Jackson's  method  with  gastroscopy  is  described  under  his 
dorsal  method  of  introduction  of  the  esophagoscope.  The  instr-uments 
are  identical,  except  that  the  gastroscope  is  longer,  as  in  Fig.  64. 

Einhorn^  has  recently  devised  a  gastroscope  in  which  the  lamp  serves 
as  an  obturator.     It  can  be  pushed  aside  at  the  time  of  inspection. 

*Jour.  Amer.  Med.  Assoc,  Feb.  25,  191 1. 
2  Ibid.,  March  4,  1911. 
*  Wiener  med.  Presse,  1881,  No.  45. 
*Med.  Record,  June  11,  1910. 


METHODS    OF   PHYSICAL   EXAMINATION    OF    THE    STOMACH  10$ 

London  reports  a  gastroscope  with  a  special  lens  system  giving  a  large 
horizon.     Sussmann's  flexible  instrument  seems  the  safest. 

I  must  confess  that  in  cases  of  suspected  cancer  or  ulcer  I  would  not 
submit  a  patient  to  the  certain  degree  of  risk  from  the  introduction  of 
an  instrument  of  the  present  type  in  an  attempt  to  make  a  diagnosis. 
The  clinical  symptoms  and  the  use  of  the  .r-rays  are  more  satisfactory 
as  well  as  safe.  In  milder  cases  of  gastric  disturbances  I  can  see  no 
advantage,  except  for  the  purpose  of  scientific  study.  It  would  seem 
that  a  large  number  of  normal  organs,  as  well  as  mild  types  of  gastric 
disease,  should  first  be  investigated  as  a  basis  for  comparison,  and  that 
the  instrument  should  be  improved  upon  before  the  method  can  be 
generally  recommended. 

The  gastroscope,  however,  is  a  valuable  adjunct  for  the  attempted 
removal  of  foreign  bodies  from  the  stomach,  such  as  a  tack,  a  pin,  etc. 


Fig.  64. — Chevalier  Jackson's  gastroscope. 

Inflating  Gastroscope  and  Duodenoscope. — These  instruments^  were 
developed  with  the  assistance  of  my  associate,  Albert  Vander  Veer,  Jr., 
for  the  purpose  of  inspection  of  the  stomach  and  duodomim  through  the 
gastric  incision,  after  laparotomy  for  a  gastric  or  intestinal  lesion,  or 
through  the  gastric  incision  for  gastro-enterostomy. 

It  has  been  impressed  upon  me  that  the  surgeon  is  often  largely  de- 
pendent upon  his  sense  of  touch  for  the  determination  of  the  location  of 
the  existing  lesion  or  lesions.^  For  example,  the  induration  of  an  ulcer 
is  distinguished  by  this  means.  One  may  at  times  fail  to  detect  an  in- 
durated ulcer  on  the  posterior  surface  of  the  stomach  by  the  method  of 
palpation,  while  a  nonindurated  ulcer  usually  will  not  be  detected  at  all.^ 

In  one  patient  suffering  from  severe  gastric  disturbances,  hyperchlor- 
hydria  with  vomiting,  the  surgeon  and  I  agreed  that  the  gall-bladder  was 
responsible.  At  operation,  it  was  found  to  be  infected  and  was  removed. 
The  stomach  was  carefully  examined  by  external  inspection  and  palpa- 
tion, with  negative  results.  The  outcome  of  the  operation  was  a  tem- 
porary improvement.  Subsequently  the  patient  suffered  from  the 
symptoms  of  gastric  ulcer,  which  ultimately  was  shown  to  be  present. 

After  several  such  experiences,  it  occurred  to  me  that  a  practical 
method  of  internal  inspection  of  the  stomach  at  the  time  of  abdominal  section 

^  N.  Y.  Medical  Journal,  Feb.  7,  1914. 
^Cancer  of  the  Stomach  (Smithies  and  Ochsner). 

'Deaver  Substantiates  this  statement  and  recommends  opening  the  stomach  for 
the  purpose  of  accurate  diagnosis.     New  York  Medical  Journal,  July  3,  1915. 


io6 


DISEASES    OF    THE    STOMACH    AND   INTESTINES 


would  be  of  value;  especially  as  incision  into  the  stomach  is  performed 
either  for  gastro-enterostomy  or  for  partial  gastrectomy,  and  the  exploring 
instrument  should  be  passed  through  that  incision,  or  through  one  in 
another  part  of  the  organ,  if  necessary. 

During  the  course  of  our  experimental  investigations  my  associate, 
Dr.  Vander  Veer,  and  myself  discovered  a  particularly  important  fact, 
that  an  ulcer  of  considerable  size  may  be  present  in  the  stomach,  so  covered 
by  the  folds  of  the  mucosa  that  it  cannot  be  seen  through  the  gastroscope, 
unless  the  organ  is  inflated. 

In  fact  in  cases  with  small  superficial  ulcer,  the  x-rays  may  only  show 
hypermotility.  On  the  other  hand,  there  may  be  several  ulcers  and  only 
one  be  determined  by  the  radiograph. 

You  will  doubtless  remember  that  in  superficial  ulceration  of  the 
stomach,  described  by  Dieulafoy,  it  has  been  demonstrated  that  even  on 
autopsy,  it  has  proved  difl5cult  to  detect  the  ulceration,  as  it  may  be  con- 
cealed in  some  of  the  folds  of  the  mucous  membrane. 


Fig.  65. — Inflating  gastroscope  and  duodenoscope. 

This  would  further  suggest  the  value  of  the  inflating  gastroscope,  to 
locate  a  hemorrhagic  lesion  requiring  suture. 

Our  instrument  is  based  on  the  principle  of  Tuttle's  inflating  procto- 
scope. The  light  carrier,  however,  must  lie  inside  the  tube,  so  as  not  to 
interfere  with  the  spherical  clamp.  There  are  six  projecting  rims  each, 
Ke  inch  in  diameter,  which  completely  encircle  the  tube,  one  at  the 
entering  tip  and  each  in  succession  an  inch  apart.  They  prevent  the 
circular  clamp  from  slipping  down.  The  rim  acts  as  a  plug  or  washer,  so 
that  when  the  edges  of  the  incision  are  drawn  up  above  it  and  the  circular 
clamp  is  applied,  no  air  can  escape.  The  circular  clamp  extends  into  a 
beak  further  to  prevent  leakage  (Fig  65). 

By  means  of  the  rims  at  various  intervals,  one  can  insert  the  tube  to 
different  distances  and  thus  explore  the  entire  stomach  from  the  fundus 
to  the  gastric  side  of  the  pyloric  ring.  The  spherical  clamp  is  covered 
with  rubber,  to  prevent  injury  to  the  musculature  of  the  stomach.  The 
eyepiece  fits  snugly  and  has  a  short  side  tube  for  attachment  of  the 
inflating  bulb,  preferably  that  employed  for   the   Tycos   sphygmoman- 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH  107 

ometer,  since  the  small  side  valve  enables  one  to  allow  the  escape  of  mod- 
erate amounts  of  air,  if  the  inflation  is  excessive. 


1 

Fig    66. — Inflation   with   the  pneumatic  gastroscope  (Manhattan   State  Hospital). 


Fig.  67. — Semi-oblique  posture  for  pneumatic  gastroscopy  (Manhattan  State  Hospital). 

The  length  of  the  instrument  is  6  inches,  and  the  diameter  nearly 
an  inch. 


Io8  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

There  is  an  introducer  which  is  subsequently  removed  and  the  eye- 
piece and  light  placed  in  position,  also  a  detachable  handle. 

We  found  by  experiment  that  elevation  of  the  shoulders  and  chest,  so 
as  to  remove  the  pressure  of  the  distended  stomach  on  the  diaphragm 
and  lungs,  is  indicated,  when  considerable  distention  is  necessary  for 
exploration. 

The  inflating  duodenoscope  is  12  inches  long;  of  a  diameter  of  3^  inch; 
the  first  projecting  rim  lies  7,}i  inches  from  the  tip;  each  succeeding 
rim  is  separated  by  an  inch.  It  is  introduced  by  direct  vision,  preferably 
through  an  initial  small  opening  in  the  stomach,  the  duodenum  being 
first  explored.  The  opening  then  can  be  enlarged  for  the  introduction 
of  the  gastroscope.  The  inflating  tube  in  this  small  instrument  is  directly 
attached  by  a  branch  to  the  main  tube,  thus  giving  more  space  for  the 
eyepiece.  The  duodenoscope  cannot  be  employed  when  there  is  marked 
pyloric  stenosis,  and  its  field  of  usefulness  is  therefore  limited. 

We  are  familiar  with  the  principle  of  the  operating  cystoscope.  This 
is  simplified  in  our  instruments.  Eyepieces  are  made  in  which  there  is 
a  small  short  tube,  through  which  thin  forceps,  or  a  curette  which  fits 
snugly  can  be  passed  and  the  necessary  procedures  carried  out  while  the 
organs  are  inflated.     This  special  eyepiece  is  usually  unnecessary. 

Sterilization  of  the  Instrument. — Various  methods  were  experimented 
with. 

We  found  as  follows: 

Five  minutes  in  80  per  cent,  alcohol.     Sterilization  complete. 

Dipped  in  a  mixture  of  3  parts  of  95  per  cent,  alcohol  and  i  part 
pure  carbolic  acid,  wiped  with  sterile  gauze  or  95  per  cent,  alcohol. 
Sterilization  complete. 

These  were  found  to  be  the  best  methods. 

The  light  carrier  should  only  be  wiped  with  80  per  cent,  alcohol,  or 
preferably  with  the  alcohol-carbolic  solution  and  then  dried  with  sterile 
gauze.  The  clamp  forceps  and  introducer  can  be  boiled;  the  eyepiece 
wiped  in  one  of  these  solutions.  The  conducting  wires  inflating  bulb  and 
battery  (Wappler  portable  six-cell  is  convenient)  should  be  covered  with 
sterile  towels.  The  gastroscope  and  duodenoscope  can  be  suspended  in 
alcohol  (80  per  cent.)  for  four  or  five  minutes,  or  preferably  for  one  minute 
in  alcohol-carbolic  solution.  No  fluid  should  he  allowed  to  enter  the  con- 
taining sheath  of  the  light  carrier.  The  instrument  can  then  be  wiped  with 
sterile  water,  dried  with  sterile  gauze  and  wrapped  up  in  it. 

A  series  of  experiments  were  carried  out  in  the  Physiological  and 
Anatomical  departments  of  the  Fordham  University  Medical  School  on 
live  dogs  and  on  the  cadaver. 

As  a  result  of  our  experiments  the  direct  pneumatic  gastroscope  may 
aid  in  determining: 

Character  and  position  of  an  ulcer. 

Number  of  ulcers  or  erosions,  and  hence  the  degree  of  resection  of  the 
stomach  required. 

Position  of  a  foreign  body  facilitating  its  rapid  removal. 

Study  of  the  pylorus. 

Point  of  endogastric  hemorrhage.     Its  rapid  ligature  is  thus  possible. 

Removal  of  a  polypus. 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH  IO9 

A  scraping  of  an  ulcerated  surface  may  be  secured  and  a  study  made 
of  the  bacterial  types  found  in  gastric  or  duodenal  ulcers,  and  hence  aid 
in  determination  of  the  etiology.  A  small  section  could  also  be  obtained 
for  examination.  This  is  not  usually  recommended,  as  chronic  ulcers  of 
the  stomach  should  be  excised. 

Some  years  ago  Rovsing  employed  an  adaptation  of  a  specially  large 
Nitze  cystoscope  combined  with  inflation,  for  examination  of  the  stomach 
and  duodenum.  Gallant  has  also  used  a  cystoscope.  We  know  of  no 
practical  direct  vision  instrument  such  as  the  present  one  heretofore 
reported. 

Gastrodiaphany  or  Transillumination  of  the  Stomach. — Casenave,  in 
1845,  first  applied  the  method  of  transillumination  to  living  tissues.  In 
1867  Milliot  succeeded  in  transilluminating  the  stomachs  of  animals 
and  experimented  with  the  stomachs  of  cadavers,  but  to  Max  Einhorn, 
of  New  York,  the  credit  is  due  of  being  the  first  to  demonstrate  transillu- 
mination of  the  stomach  on  the  living  subject  and  the  practical  value  of 
gastrodiaphany.  His  instrument,  which  he  denominates  a  gastrodiaphane 
consists  of  a  soft-rubber  stomach-tube,  at  one  end  of  which  is  fastened  an 
Edison  lamp.  Conducting  wires  run  through  the  tube  to  the  battery, 
and  there  is  a  current  interrupter  at  some  distance  from  the  tube.  The 
lamp  is  inclosed  in  a  glass  bulb,  to  act  as  a  reflector  and  prevent  the  ac- 
tion of  heat  on  the  stomach.  He  has  the  patient  drink  only  one  or  two 
glasses  of  water,  so  as  not  to  distend  the  stomach,  inserts  the  light,  and  ex- 
amines the  case  in  a  dark  room,  either  in  the  sitting  or  in  the  recumbent 
position. 

Heryng  and  Reichmann  employ  a  modified  tube,  with  a  wate.r-cooler 
about  the  lamp.  Kuttner  and  Jacobson,  under  Ewald's  direction, 
performed  a  great  number  of  experiments. 

These  experimenters,  together  with  Meltzing,  are  the  chief  foreign 
investigators  with  gastrodiaphany.  Manges,  Stockton,  and  many  others 
have  employed  it.  Among  various  gastrodiaphanes  are  those  of  Hem- 
meter,  Lincoln,  Solis-Cohen,  Koplik,  and  Lockwood.  To  Lockwood  we 
must  credit  a  decided  advance  in  the  type  of  instrument — a  fine,  wire- 
bound  cable  (rubber  insulated)  and  a  small  light,  no  larger  than  a  5-grain 
capsule.  The  cut  of  my  instrument,  the  "circumscribing  gastrodia- 
phane," will  sufficiently  explain  the  Lockwood  instrument,  after  which 
it  is  modeled,  with  certain  additions. 

The  Circumscribing  Gastrodiaphane. — A  series  of  observations  with 
transillumination  of  the  stomach  suggested  an  improvement  on  the  gas- 
trodiaphanes in  use.  Manipulation  of  the  tube  after  the  electric  light 
has  entered  the  stomach  frequently  causes  gagging  and,  at  times,  vomit- 
ing, interfering  thus  with  the  accuracy  of  the  method.  The  cables  of 
all  the  instruments  were  found  unsatisfactory  in  cases  of  gastroptosis  of 
great  degree  when  we  endeavored  to  explore  carefully  the  pyloric  end  of 
the  greatly  dilated  stomach.  It  was  impossible  to  guide  the  light  in  a 
definite  direction;  it  would  sometimes  pass  to  the  right,  sometimes  to  the 
left,  and  often  it  was  necessary  to  draw  it  in  and  out  a  number  of  times 
for  a  distance  of  several  inches. 

The  instrument  I  devised  to  overcome  these  drawbacks  has  a  cable 


no 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


about  6  inches  longer  than  the  Lockwood  gastrodiaphane,  and  is  of  about 
the  same  caliber  (Fig.  68).  The  cable  is  more  flexible  for  the  space  of  }i 
inch  at  about  the  same  distance  from  the  light — in  effect,  a  joint  at  this 
point.  At  the  base  of  the  light  is  attached  an  extremely  thin  accessory- 
cable,  covered  with  rubber.  This  runs  parallel  with  the  main  cable  and 
increases  the  diameter  only  a  very  slight  degree.  After  introduction  of 
the  instrument  the  main  cable  is  held  firmly,  and  the  accessory  cable  drawn 
upon.  By  turning  the  cable  at  the  same  time,  the  instrument  can  be 
guided  in  the  desired  direction.  By  manipulation  of  the  accessory  cable 
the  main  cable  can  be  so  bent  that  the  light  will  explore  the  entire  wall 
of  the  stomach  anteriorly,  and  can  be  made  to  pass  up  to  the  pylorus  and 
along  the  borders  of  the  ribs.     The  lesser  curvature  is  thus  explored. 

Care  should  be  taken  that  the  cables  are  parallel  when  passed  into 
the  stomach,  and  the  accessory  cable  should  be  relaxed  before  withdrawal. 
The  main  cable,  except  at  the  joint  near  the  light,  is  stiffer  than  the  Lock- 


Fig.  68. — Kemp's  gastrodiaphane  (circumscribing). 

wood  light.  Eight  dry  cells  are  employed  with  a  rheostat.  Wappler 
manufactures  a  small  pocket  battery  with  six  cells  which  I  have  found 
excellent.  An  extra  lamp  should  be  carried.  Water  was  the  medium 
formerly  employed. 

A  great  advance  in  the  technic  of  gastrodiaphany  is  the  employ- 
ment of  fluorescent  media.  ^ 

There  are  three  such  media  found  to  be  of  value: 

Bisulphate  of  quinin,  lo  grains  (o.6),  in  a  pint  of  water.  The  addi- 
tion of  5  minims  (0.3)  of  dilute  phosphoric  acid  intensifies  its  action. 
The  same  amount  of  dilute  sulphuric  acid  may  be  substituted.  The 
reaction  of  the  quinin  solution  is  acid  and  the  fluorescence  a  very  pale 
violet.  Increased  acidity  intensifies  its  action  and  fluorescence  disappears 
if  the  solution  is  rendered  alkaline. 

Esculin.  This  is  derived  from  the  ^sculus  hippocastanum  (horse- 
chestnut),  indigenous  to  Europe;  15-grain  doses  have  been  used  in  malaria. 

1  New  York  Med.  Jour.:  Philadelphia  Med.  Jour.,  Feb.  i;j,  1904;  New  York  Med. 
Jour.,  August  6,  1904. 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH 


li£ 


One  can  employ  small  doses,  >^  to  H  grain  (0.008-0.032),  in  a  pint  of 
alkaline  solution,  which  gives  a  blue  fluorescence.  This  preparation  is 
difl&cult  to  secure  and  is  expensive. 

Fluorescein  (phthalic  anhydrid,  5  parts),  a  naphthalin  product,  and 
resorcin  (7  parts),  heated  to  2oo°C.  (392°F.).  It  is  a  reddish  powder, 
faintly  soluble  in  water,  with  a  neutral  action,  and  gives  thus  no  fluores- 
cence; soluble  in  alcohol  and  in  alkaline  media,  it  gives  a  green  fluorescence 
like  liquid  opal.  It  has  been  employed  to  detect  ulcers  of  the  cornea. 
It  can  be  secured  from  Merck  &  Co.,  and  is  extremely  cheap. 

The  addition  of  glycerin  intensifies  the  fluorescence,  and  the  hy- 
drochloric acid  of  the  stomach  must  first  be  neutralized.  The  patient 
should  first  be  given  a  glass  of  water  (8  oz. — 250  c.c.)  in  which  15  grains 


D 


Fig.  69.- 


-Gastrodiaphany :  A,  Normal   stomach;   B,   dilated   stomach;   C,  D,  E,  F, 
varying  degrees  of  gastroptosis  (Rose  and  Kemp). 


(i)  of  bicarbonate  of  soda  have  been  dissolved.  A  second  glass  of  water 
(8  oz. — 250  c.c.)  is  then  administered,  in  which  are  dissolved  the  same 
amount  of  sodium  bicarbonate,  i  dram  (4)  of  glycerin,  and  ^  grain 
to  several  grains  (a  small  amount  on  a  knife  tip)  of  fluorescein; 
I  or  2  ounces  of  hme-water  may  be  substituted  for.  the  sodium 
bicarbonate. 

If  we  increase  the  fluorescein  much  in  strength,  fluorescence  diminishes 
and  colorization  begins.  By  means  of  fluorescent  media  I  have  found 
it  possible  to  illuminate  the  stomachs  of  fat  or  muscular  subjects  that  were 
formerly  unsatisfactory,  and  to  examine  for  tumors  and  for  the  location 
of  the  stomach  with  greater  accuracy.  The  brilliancy  of  the  illumination 
is  markedly  increased. 


112 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Examination  of  the  urine  of  patients  who  have  taken  fluorescein  shows 
no  deleterious  effects — no  albumin,  no  sugar,  no  casts.  The  fluorescein 
acts  in  an  alkaline  medium,  and  free  acid  destroys  fluorescence,  yet  on 
catheterization  of  these  patients,  greenish  fluorescent  urine  is  obtained  one 
hour  after  the  administration  of  fluorescein  solution,  and  this  condition 
persists  for  about  four  hours.  The  acidity  of  the  urine  is  not  due  to  the 
presence  of  free  acid.  With  fluorescein  solution  we  have  an  additional 
means  of  testing  the  permeability  of  the  kidneys. 

The  technic  of  gastrodiaphany  is  as  follows:  The  patient's  stomach 
should  be  empty.  He  is  given  a  glass  (8  oz. — 250  c.c.)  of  the  alkaline 
solution,  and  then  a  second  glass  (8  oz. — 250  c.c.)  of  the  fluorescein  solu- 
tion. I  frequently  give  an  extra  half  or  even  two  additional  glasses  of  water, 
especially  in  the  suspected  cases  of  dilatation  or  ptosis  or  in  stout  subjects. 
In  the  latter,  gastrodiaphany  is  not  as  satisfac- 
tory, but  by  pressing  on  the  abdominal  wall,  the 
outlines  can  be  secured. 

A  dark  room  gives  the  most  satisfactory  re- 
sults. It  can  be  devised  by  pinning  blankets 
across  the  windows.  The  patient  can  also  be 
examined  in  a  light  room  by  covering  him  from 
neck  to  feet  with  a  dark  blanket  or  black  gown, 
and  the  examiner  looking  through  an  opening 
therein. 

The  gastrodiaphane  is  introduced  by  gas- 
light or  candlelight,  the  patient  sitting  oppo- 
site in  a  chair,  with  the  abdomen  exposed. 
The  electric  current  is  turned  on  and  the  room 
darkened.  The  patient  should  then  stand  up, 
as  this  position  is  preferable.  It  is  my  custom 
to  mark  out  the  anatomic  regions  on  the  abdo- 
men of  each  case  with  blue  pencil,  and  then  draw  the  outlines  of  the 
stomach  during  transillumination. 

With  gastroptosis,  the  lesser  curvature  can  be  determined.  In  some 
cases  the  stomach  will  be  bottle-neck  above,  with  the  base  below;  or 
somewhat  pear  shaped,  the  narrow  part  showing  above,  as  the  light  dis- 
appears beneath  the  ribs.  With  a  dilated  stomach  the  transverse  diameter 
of  transillumination  is  nearly  the  same  throughout;  as  we  withdraw  the 
light  it  begins  to  narrow  just  below  the  tip  of  the  ensiform.  If  we  illu- 
minate in  the  dorsal  position,  the  light  hardly  shows  at  all;  it  becomes 
clearer  as  the  patient  gradually  sits  erect,  and  is  most  marked  in  the 
standing  position.  This  substantiates  the  view  of  Meltzing,  who  states 
that  in  the  dorsal  position  only  a  portion  of  the  stomach  is  in  contact 
with  the  abdominal  wall,  and  it  demonstrates  the  necessity  of  the  standing 
position  for  accurate  illumination. 

In  Fig.  69  are  shown  a  normal  stomach,  the  dilated  organ,  and  several 
degrees  of  gastroptosis.  There  is  no  question  but  that  ptosis  of  the 
stomach  exists  from  a  very  slight  to  an  extreme  degree.  Tumors  or  thick- 
enings of  the  anterior  wall  of  the  stomach,  or  of  the  lesser  or  greater  cur- 


Fig.  70. — Cancer  of 
greater  curvature.  Gas- 
trodiaphany. 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH  II3 

vature,  or  anterior  surface  of  the  pylorus,  appear  as  a  dark  area  projecting 
into  or  surrounded  by  a  light  zone  (Fig.  70). 

By  the  circumscribing  gastrodiaphane  the  entire  contour  of  the 
stomach  is  determined.  The  older  instruments  show  only  the  lower 
segment  clearly. 


RONTGEN  RAY  (X-RAYS)  IN  THE  DIAGNOSIS  OF  DISEASES  OF  THE 
ESOPHAGUS  AND  STOMACH 

Unquestionably  the  discovery  of  the  x-Ta,ys  constitutes  one  of  the 
greatest  advances  in  medicine  in  recent  times,  and  their  application  to 
diagnosis  in  gastro-intestinal  diseases  has  proved  of  great  value. 

The  Esophagus. — By  means  of  the  rc-rays  the  scientific  study  of  the 
motor  functions  of  the  esophagus  has  been  rendered  possible.  One 
can  readily  make  a  diagnosis  of  stenosis  of  the  esophagus  or  of  a  diver- 
ticulum by  the  methods  already  described.  The  x-rays  after  the  ingestion 
of  bismuth  or  barium  are  of  value  as  an  adjunct.  One  can  thus  readily 
determine  the  contour  and  relations  of  a  diverticulum  to  the  esophagus 
(Figs.  23,  24,  and  25),  a  fusiform  dilatation,  a  stricture,  abnormalities  due 
to  adhesions,  fistulse  alternations  of  outline,  and  pressure  of  aneurysm  or 
tumor.  The  author  advocates  the  use  of  .T-rays  when  possible,  though 
generally  one  can  make  the  diagnosis  without  their  use.  The  position  of 
a  foreign  body  can  usually  be  determined  by  direct  inspection  through  the 
esophagoscope,  and  can  be  at  the  sanje  time  removed.  A  preliminary 
rontgenograph  is  preferable  when  possible. 

The  Stomach. — From  a  scientific  standpoint,  the  study  of  the  stomach 
with  the  a;-rays  has  proved  of  great  service.  It  has  been  demonstrated 
that  the  fundus  is  vertical  and  the  pyloric  portion  is  transverse,  and  that 
the  viscus  does  not  lie  transversely  across  the  abdomen,  as  was  formerly 
supposed.  Cannon  has  also  made  an  interesting  study  of  the  motility  of 
the  stomach  by  means  of  the  x-rays,  and  also  of  the  relative  rapidity  of 
the  exit  of  the  carbohydrates,  proteins,  and  fats  from  this  organ. 

From  a  practical  standpoint  Rontgenography  is  of  great  value  for  the 
detection  of  a  foreign  body  lodged  within  the  stomach  and  for  demonstrat- 
ing its  location.  The  possibility  of  its  removal  through  the  gastroscope, 
or  the  location  of  an  incision  for  its  removal,  often  depends  upon  the 
information  secured  by  this  means.  The  author's  new  gastroscope,  when 
laparotomy  is  required,  simplifies  its  removal. 

The  Rontgeno-cinemetographic  method  has  enabled  us  to  make  a 
scientific  study  of  the  digestive  tract  to  determine  the  normal  changes  in 
the  contour  of  the  stomach  and  intestines,  the  types  of  peristaltic  waves, 
motility,  etc.  There  has  been  a  tendency  to  make  a  positive  diagnosis 
from  the  .a"-ray  findings  alotie,  disregarding  the  clinical  symptoms.  The 
writer  notes  that  recently,  uncertainty  is  often  expressed  as  to  the  dififer- 
ential  diagnosis  between  gastric  ulcer  and  early  cancer  as  determined 
from  the  radiographs  alone,  and  chronic  ulcer  is  considered  a  pre- 
cancerous stage,  which  view  I  believe  is  correct.  The  diagnosis  should 
be  made  from  the  history,  clinical  symptoms,  and  physical  examination  plus 
the  rc-rays.  These  will  determine  whether  or  not  the  case  is  surgical.  I 
8 


114  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

believe  that  in  most  cases  the  large  number  of  serial  pictures  40,  to  80, 
are  unnecessary.  Even  the  brief  exposures  to  a  powerful  tube,  might  in 
some  cases  be  the  equivalent  to  a  longer  exposure  to  a  weaker  tube  and 
do  harm,  and  the  method  is  tiresome,  and  expensive  for  the  patient. 
Surgical  operation  and  pathological  examination  settle  the  diagnosis. 

A  picture  taken  immediately  after  the  ingestion  of  the  bismuth  meal; 
one  every  fifteen  minutes  for  the  first  hour  and. in  some  cases,  four  to  six 
pictures  in  all  at  six-second  intervals  are  required.  At  the  end  of  one, 
two  and  six  hours  radiographs  are  taken  of  the  stomach  and  intestines. 
Then  a  bismuth  or  barium  enema  with  radiograph  standing;  then  five 
minutes  in  the  knee-chest  position — followed  by  a  radiograph  in  the  Tren- 
delenburg position.  These  last  procedures  suggested  by  Wm.  P.  Healy 
are  of  great  value,  particularly  in  cases  of  enteroptosis  when  a  mass  of 
intestines  may  lie  in  the  pelvis.  It  will  determine  whether  the  intestines 
are  freely  movable  or  are  bound  down  by  adhesions  not  showing  in  the 
radiograph.  Tousey  i:ecently  radiographs  in  an  oblique  position  lying 
on  the  belly,  head  downward.  The  stomach  should  be  radiographed 
both  in  the  dorsal  and  standing  positions  and  at  times  on  the  right  side 
particularly  in  stout  patients  to  obtain  a  better  picture  of  the  duodenal 
cap  (ascending  duodenum).  Fluorscopic  examination  is  recommended 
by  many — alone  or  combined  with  palpation  in  addition  to  radiography. 
It  would  seem  to  endanger  some  risk  to  the  patient  and  operator  in  spite 
of  the  precautions  observed,  the  personal  equation,  with  possibility  of 
error  is  more  likely  and  the  method  less  accurate  than  photography. 
Marked  success  has  also  been  claimed  for  stereo-radiography.  It  is  not 
within  the  province  of  this  article  to  describe  the  technic  of  the  rc-ray 
examination,  but  it  seems  more  practical  and  for  the  benefit  of  the  reader, 
that  as  a  clinician  the  writer  should  endeavor  to  interpret  the  most 
important  radiographs  of  the  gastro-intestinal  tract.  ^ 

The  Duodenal  Cap. — The  normal  cap  (ascending  duodenum)  is  in 
the  a;-ray  picture  usually  triangular  in  shape — the  base  lying  at  the  pyloric 
ring  and  parallel  with  it.  Compare  the  normal  cap  (Fig.  71  A)  with  that 
deformed  by  ulcer  (B). 

It,  however,  may  be  drawn  down  like  the  modern  basket  hat  over  the 
pyloric  end,  or  the  position  may  diflfer  slightly  depending  on  the  type  of 
stomach.  The  cap  may  also  be  somewhat  squarer  in  shape  or  in  the  form 
of  a  parallelogram.  Under  normal  conditions  there  are  no  irregularities 
in  its  contour  except  occasionally  a  slight  indentation  from  the  adjoining 
duodenum.  With  dilated  stomach  from  obstruction  at  the  pars  pylorica, 
there  is  a  disappearance  of  a  portion  of  this  last,  including  the  cap.  With 
atonic  dilatation,  there  is  no  disturbance  in  the  contour  of  the  stomach  and 
the  pylorus  is  relaxed. 

Gastric  Ulcer. — Radiological  Findings. — i.  Bismuth  retention  six 
hours  after  the  meal  shows  mechanical  interference  with  the  exit  of  the 
gastric  contents  due  to  tumor,  cicatricial  contracture  of  the  pylorus  from 
ulcer,  or  ulcer  adhesions,  or  gall-bladder  adhesions.  Such  retention  also  oc- 
curs with  atonic  dilatation  of  the  stomach,  but  the  outline  of  the  organ  is 

^  Unless  otherwise  noted,  the  radiography  of  all  cases  in  this  volume  is  the  work  of 
Sinclair  Tousey  on  private  patients  of  the  author. 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH 


115 


normal  in  this  condition,  while  it  is  irregular  at  some  point  from  ulcer  con- 
traction, tumor  or  adhesions.  Pylorospasm  associated  with  hyperchlorhy- 
dria,  secondary  to  chronic  appendicitis,  gall-bladder  infection  or  intra-ab- 
dominal adhesions,  such  as  occur  with  Lane's  kink,  may  cause  bismuth 
retention.  Cole  holds  spasm  of  the  cap  to  be  responsible  and  that  he 
can  determine  it  by  the  x-rays.  Correction  of  the  hyperacidity  (which 
the  writer  believes  is  often  reflex  from  the  other  conditions  and  the  spasm 
secondary)  by  belladonna,  antacids,  etc.,  will  at  times  temporarily  re- 
lieve the  spasm.  The  preliminary  use  of  these  before  radiography  usually 
eliminates  it.  Chronic  appendicitis  is  not  particularly  difficult  to 
diagnose,  especially  if  one  examines  Morris^  point  as  well  as  McBurney's. 
It  can  often  be  determined  by  the  former — when  not  by  the  latter. 
Further  radiographs  of  the  intestines  and  the  clinical  history  afford  us 
the  required  diagnosis. 


Chyme  passing  through  lumen  of  pyloric  Clinical   diagnosis:   Ulcer  of   the   cap. 

sphincter  into  reservoir  cap.  A,  Pilleus  Rontgenologic  diagnosis :  Ulcer  of  the  cap. 
ventriculi  (cap).  B,  Pyloric  sphincter.  C,  Surgical  findings :  Ulcer  of  the  cap.  Case  i 
Lumen  (normal)  (L.  G.  Cole).  (Brewer»and  Cole). 

Fig.  7 1 . — Compare  normal  cap  (ascending  duodenum)  with  deformed  cap  from  ulcer. 


In  Fig.  72  is  depicted  a  case  of  the  author's.  The  patient,  aged  58, 
had  gastric  disturbance  for  many  years — becoming  worse  two  years 
previously,  and  had  lost  25  pounds  in  the  course  of  a  few  months.  He 
has  vomited  once  or  twice  daily  of  late.  The  gastric  analysis  was  typical 
neither  of  benign  nor  malignant  stenoses — total  acidity  60 -f,  no  occult 
blood  in  stomach-contents  or  stool.  The  writer  believed  the  case  to  be 
benign  stenosis  due  to  ulcer,  no  tumor  palpable.  The  radiograph  shows 
marked  retention  of  gastric  contents,  with  disappearance  of  the  pylorus 
and  cap.  It  did  not  differentiate  between  simple  adhesions,  with  or 
without  ulcer,  and  carcinoma.  Operation  disclosed  perforated  gastric 
and  duodenal  ulcers  well  walled  in  with  a  mass  of  adhesions — nearly 
obliterating  the  pylorus  and  cap  and  adherent  to  the  pancreas. 

2.  In  some  cases,  when  the  ulcer  lies  upon  the  lesser  curvature,  it  may 
cause  contraction  of  the  upper  border  of  the  stomach,  thus  bringing  the 
cardia  and  pylorus  closer  together,   the  latter  being  displaced  (drawn) 


ii6 


DISEASES    OF    THE    STOMACH    AND   INTESTINES 


upward  and  to  the  left,"  so-called  "snail  form."  Ulcer  at  the  pylorus, 
on  the  greater  curvature,  like  cancer,  may  produce  the  "undershot 
stomach"  with  pyloric  stenosis. 

3.  Penetrating  ulcer  of  the  stomach  shows  a  patch  branching  out  from 
the  bismuth  or  barium  meal,  or  at  times  isolated  from  it.  In  the  latter 
event  there  may  be  a  gas  bubble  at  the  summit  of  the  patch. 

4.  Bismuth  or  Barium  Patch  on  Shallow  Ulcer. — In  Fig.  73  a  case  of  the 
writers  at  the  upper  end  of  the  radiograph  is  a  black  patch  marked  +. 


Fig.  72. — Perforating  gastric  and .  duodenal  ulcers  (posterior).  Adhesions  sur- 
rounding pylorus  and  cap.  Pancreas  attached  by  adhesions.  Ulcers  were  walled  ofiF 
by  adhesion.  Condition  was  evidently  chronic.  Bismuth  retention  marked  at  end  of 
six   hours.     Stomach  dilated  and  ptosed. 


This  represents  a  bismuth  deposit  on  a  shallow  ulcer  surface,  six  hours  after 
the  bismuth  meal.  By  comparison  with  radiographs  taken  directly  after 
the  meal — this  patch  was  demonstrated  to  lie  near  the  cardiac  orifice 
probably  posteriorly.  This  patient  suffered  from  hyperacidity,  hyper- 
secretion and  chronic  gall-bladder  infection  of  mild  type.  Abdominal 
section  demonstrated  infected  gall-bladder  which  was  removed.  The 
operator  palpated  the  stomach  and  duodenum  with  particular  care  and 
examined  them  as  usual,  as  far  as  possible.  No  ulcer  could  be  determined. 
For  a  few  months  there  was  marked  improvement  but  attacks  of 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH  II7 

hypersecretion,  headache  and  vomiting,  still  occurred  later.  Five  months 
after  operation  the  condition  was  nearly  as  bad  as  before.  The  ulcer 
was  determined  by  the  rc-rays  subsequent  to  operation.  Unquestionably 
bismuth  deposit  will  not  occur  on  some  ulcers  and  when  there  is  little 
or  no  cicatricial  contraction,  no  deformity  may  be  appreciable  so  that 
hypermotility  may  alone  show  in  the  radiographs — accompanied  sometimes 
by  pyloric  spasm  and  retention.  Hypersecretion  can  best  be  determined 
by  Reichmann's  method. 

On  the  other  hand  a  bismuth  patch  does  not  always  necessarily  mean 


Fig.  73. — Bismuth  deposit  on  a  shallow  ulcer  (at  +)  surface,  six  hours  after  bis- 
muth meal.  Infected  gall-bladder  removed.  Palpation  at  operation  could  determine 
no  ulcer.  Hyperacidity  and  hypersecretion  present.  Ulcer  demonstrated  by  radio- 
graph subsequent  to  operation. 

ulcer.  In  a  case  of  gastroptosis  with  a  history  of  gastric  disturbance 
formerly  marked  and  more  lately  less  severe,  there  was  a  bismuth  patch 
of  fair  size  near  the  fundus.  There  were  no  clinical  evidences  of  ulcer. 
Evidently  the  patch  was  due  to  contractions  from  an  old  healed  ulcer, 
or  from  adhesions,  with  resulting  bismuth  deposit  in  the  irregularities. 
Motility  was  disturbed  in  that  area.  Clinical  conditions  must  therefore 
be  also  considered  in  arriving  at  our  diagnosis. 

5.  Deformity  of  the   contour  of  the  stomach  without   pyloric  stenosis 
may  occur,  such  as  a  saddle-back  ulcer  of  the  lesser  curvature. 


ii8 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


6.  A  small  puckered  area  with  distortiDn  of  the  rugae  is  suggestive 
of  gastric  ulcer,  particularly  if  the  region  fails  to  contract  with  the  rest 
of  the  organ  and  when  this  area  coincides  with  tenderness  on  palpation. 

7.  Distortion  or  displacement  of  the  stomach  or  cap  by  adhesions 
is  suggestive  of  gastric  or  duodenal  ulcer.  In  most  cases  the  pyloric 
sphincter  and  cap  are  involved.  The  sphincter  is  not  clear  cut  and  is 
wider  on  one  surface  appearing  wedge-shaped  or  on  both  surfaces  with 
an  annular  appearance  (Cole).  The  cap  may  be  contracted,  asym- 
metrical, displaced  or  even  absent.  Peristaltic  contractions  are  clean- 
cut  in  the  normal  portion  of  the  stomach  but  are  irregular  or  cease  at 
the  point  of  adhesions. 

The  stomach  may  be  bound  to  an  adjacent  viscus  and  radiographs 
taken  in  the  dorsal,  standing  and  Trendelenberg  posture  may  aid  in  the 

determination  of  that  viscus,  to 
which  there  are  adhesions. 

There  is  usually  a  deep  incisura 
on  the  opposite,  non-adherent 
portion  of  the  stomach.  It  may 
occur  opposite  to  or  slightly  to  the 
cardiac  side  and  represents  com- 
pensatory hypermotility  of  the 
organ  or  it  may  be  due  to  spasm 
^,0>^ — v,^  ^^  ^  \  (Carman).^  Diffuse  spasm  of  the 
A^  ^*i^^?;>*^  J     I   pg^jg    pylorica    or    pylorus    alone 

with  retention  of  contents  may 
also  occur.  Adhesions  to  the  gall- 
bladder or  liver  generally  result 
in  the  stomach  being  held  up  more 
horizontally.  With  gall-bladder 
infection  and  adhesions  there- 
from, the  cap  is  often  angulated  and  drawn  more  to  the  right,  so 
that  the  lumen  is  more  horizontal  than  vertical.  It  is  not  always  possible 
in  the  writer's  opinion  to  differentiate  between  adhesions  ivova.  gall-bladder 
infection,  or  adhesions  from  ulcer.  The  radiograph  shows  that  the 
condition  requires  surgical  procedure. 

8.  Hour-glass  contraction  occurs  at  times  as  a  sequel  to  gastric  ulcer 
as  in  Fig.  74.  A  spastic  hour-glass  contraction  is  at  times  seen  with 
ulcer  of  the  lesser  curvature  particularly  if  it  is  adherent  to  the  under- 
surface  of  the  liver.  The  incisura  (indentation)  occurs  on  the .  greater 
curvature  only.  It  may  be  found  on  some  plates  and  not  in  others, 
and  may  disappear  in  the  dorsal  position.  Spasm  of  the  pars  pylorica  or 
entire  stomach  may  be  due  to  extrinsic  causes  such  as  disease  of  the  ap- 
pendix, gall-bladder,  pancreas,  etc.  It  can  be  generally  excluded  by 
belladonna  gtts.  10-20  t.i.d.  several  days  before  examination. 

Duodenal  Ulcer. — Radiological  Findings. — There  is  considerable  dis- 
pute among  our  radiologists  as  to  which  should  be  considered  the  major 
and  minor  radiological  signs  of  this  condition.     Cole  of  New  York, 
places  most  confidence  in  changes  in  contour  of  the  cap  as  the  most  im- 
'  Journal  A.  M.  A.  (Carman)  April,  22,  1916. 


Fig.  74. — Hour-glass  contraction  of 
stomach  secondary  to  ulcer.  Local  pain. 
Seven  years  previously  blood  in  the  stool. 
"Pain  aggravated  by  food.  Previous  history 
of  ulcer  (MacFarlane  in  N.  Y.  State  Jour,  of 
Med.). 


METHODS    OF    PHYSICAL    EXAMINATION    OF    THE    STOMACH  II9 

portant  feature,  while  Carman  of  Rochester,  Minn.,  believes  that  with 
ulcers  chiefly  limited  to  the  mucosa,  or  not  extending  deeply  and  with 
slight  visible  scar  production  but  no  marked  contraction  or  deformity, 
that:  I.  gastric  hyperstalsis  is  the  chief  radiological  symptom,  and  that 
deformity  of  the  cap  may  not  necessarily  occur.  Undoubtedly  with 
superficial  ulceration  of  the  duodenum  no  changes  may  occur  in  the  cap 
to  cause  marked  distortion,  though  I  believe  some  bismuth  or  barium 
retention  or  slight  irregularity  would  be  found  in  most  cases. 

Carman's  contention  that  stenotic  lesions  on  the  gastric  side  of  the 
pylorus  are  rarely  accompanied  by  gastric  hyperperistalsis  is  not  well 
founded,  especially  in  some  cases  of  stenotic  dilatation  of  the  stomach. 
The  phenomenon  of  peristaltic  unrest — hyperstaltic  action  of  the  stomach 
with  waves  visible  through  the  abdomen  is  a  clinical  entity.  Radiographs 
at  this  time  might  show  exaggerated  peristaltic  action  on  the  part  of  the 
stomach  in  endeavoring  to  overcome  the  pyloric  obstruction.  More- 
over, this  type  of  stomach  pathologically  gives  evidence  of  a  hypertrophy 
of  the  musculature  at  the  pyloric  end  of  the  stomach,  an  endeavor  to 
compensate  for  the  obstruction"  and  an  evidence  of  exaggerated  muscular 
activity.  Most  frequently  of  course  there  is  retention  without  hyper- 
peristalsis as  the  radiographs  are  generally  taken  during  the  quiescent 
period.  With  pylorospasm  associated  with  hyperacidity,  during  the 
active  spasm  we  may  have  hyperperistalsis.  Furthermore,  uncured  pyloro- 
spasm may  result  in  hypertrophic  pyloric  stenosis.  Finally,  in  the  event 
of  the  inability  to  overcome  the  obstruction  (organic  or  spasmodic) — 
reversed  peristalsis  (antiperistalsis)  occurs  and  vomiting  follows. 

We  place  i.  gastric  hyperperistalsis^  as  one  of  the  radiological  signs 
of  duodenal  ulcer  contributory  to  our  diagnosis,  when  present,  though 
it  may  also  occur  with  gastric  ulcer,  or  erosions. 

2.  Retention  of  bismuth  in  the  stomach  after  six  hours  occurs  in 
some  cases  with  hyperstalsis  (gastric). 

3.  Irregularities  or  deformity  of  the  cap  (ascending  duodenum)  or 
of  the  sphincter  pylori  produced  by  the  induration  surrounding  the  crater 
of  an  ulcer  or  resulting  from  it.  These  signs  so  ably  described  by  Cole^ 
are  of  extreme  importance.  The  indurated  ulcer  may  project  into  the 
lumen  of  the  cap  (Fig.  75)  and  cause  a  displacement  of  barium  or  a  dent,  or 
entirely  distort  the  lumen,  or  half  the  cap  may  be  involved.  In  some  cases 
one  sees  only  a  pocket  filled  with  barium,  or  a  barium  pocket  lying  in 
a  distorted  cap.  Sometimes  the  deformity  lies  along  side  the  sphincter 
pylori  and  may  involve  it. 

In  other  cases,  the  cicatricial  contraction  may  practically  obliterate 
the  cap  and  it  is  doubtful  whether  one  can  differentiate  this  as  due  to 
induration  or  adhesions.  In  addition  to  the  deformity  of  the  cap — 
adhesions  may  pass  to  the  gastric  side  of  the  sphincter  and  distort  the 
pyloric  end  of  the  stomach  giving  the  aspect  much  like  the  snail  form  of 
stomach  as  in  gastric  ulcer. 

About  90  per  cent,  of  duodenal  (post-pyloric)  ulcers  lie  in  the  cap 

1  Journal  A.  M.  A.,  May,  8,  1914. 
*  Lancet,  May  2,  1914. 


I20 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


(ascending  duodenum)   though  other   times   they  occur  lower  in  that 
viscus. 

4.  Lagging  or  retention  of  bismuth  or  barium  in  the  duodenum,  or  a 
dilated  cap,  or  an  accumulation  of  bismuth  or  barium  filling  part  of  the 
duodenum  may  be  due  to  ulcer,  or  ulcer  contraction  adhesions  from  ulcer, 
or  other  adhesions  such  as  from  the  gall-bladder. 

5.  A  diverticulum  in  the  cap  from  perforating  ulcer  is  a  major  sign 
described  by  Carman  who  also  refers  to  minor  signs  such  as 


Fig.  75. — Fish-hook  stomach.  Marked  peristalsis  at  pyloric  end  (hyperperistalsis) 
cap  small  and  slightly  irregular  (c).  Hyperchlorhydria.  Four  months  history.  No 
hemorrhage.  No  occult  blood  on  several  examinations.  Point  of  tenderness  corre- 
sponds to  cap.  Improved  for  a  time  under  treatment,  then  relapsed.  Operation 
advised  but  refused.     Diagnosis.     Duodenal  ulcer. 


6.  Gastric  hypermotility  with  early  opening  of  the  pylorus  and  rapid 
emptying  of  the  stomach  when  no  stenosis  is  present. 

7.  Gastric  hypertonus. 

8.  Spasms  of  the  stomach  such  as  hour-glass,  or  slow  traveling  in- 
cisura. 

The  writer  finds  deformity  of  the  cap  and  hyperstalsis  with  a  six-hour 
residue,  the  most  reliable  radiological  data.  In  some  cases  there  may 
be  lagging  of  bismuth  in  the  cap,  or  a  large  accumulation  therein  and  more 
rarely  a  diverticulum.     Deformity  of^  the  cap  is  the  most  frequent  sign 


METHODS    OF    PHYSICAL   EXAMINATION    OF    THE    STOMACH  121 

elicited.     Constriction  of    the  duodenum    by  adhesions  or  a  mesenteric 
band  may  simulate  duodenal  ulcer. 

Simulation  of  symptoms  of  duodenal  ulcer  caused  by  rolling  up  and 
thickening  of  part  of  the  mesentery,  constricting  the  duodenum  and  passing 
to  the  transverse  colon  near  the  hepatic  flexure.  This  patient  had  been 
ill  twenty  months  with  stomach  trouble,  belches  gas — suffers  from  nausea 
— no  vomiting.  Has  attacks  of  pain  in  the  stomach  which  are  relieved 
by  food.     These  occur  two  to  three  hours  after  meals.     Bowels  costive. 


Fig.  76. — Fish-hook  stomach.  Hyperperistalsis  particularly  in  pyloric  region. 
Cap  enlarged,  +,  with  bismuth  lagging  in  same.  Believed  to  be  due  to  duodenal  ulcer 
near  end  of  ascending  duodenum  (apex  of  cap).  Patient  has  local  pain  and  tenderness 
corresponding  to  this  point.  Operation  shows  no  ulcer,  no  ulcer  scar,  but  thickened 
mesenteric  band  exercising  traction  at  junction  of  ascending  and  descending  duodenum. 
It  does  not  surround  the  gut.     Bismuth  eventually  deposited  above  traction  point. 

On  one  occasion  he  found  blood  in  his  mouth  which  he  believed  was 
belched  or  regurgitated  from  the  stomach. 

Slight  tenderness  was  present  on  pressure  in  the  epigastrium  a  little 
to  the  right  of  the  median  line.  Gastric  analysis  showed  hyperacidity  and 
no  occult  blood.  No  occult  blood  in  the  stool.  Diagnosis  ^' Hyper chlor- 
hydria"  with  probable  ulcer  of  the  duodenum.  Finally  several  months 
later,  pain  and  tenderness  persisting,  the  patient  consented  to  an  .r-ray 
examination.     The  results  appear  in  Figs.  76  and  77.     There  was  hyper- 


122 


DISEASES    or    THE    STOMACH    AND    INTESTINES 


motility  particularly  marked  at  the  pyloric  end  yet  the  cap  was  unduly 
large  and  showed  lagging  of  bismuth.  Six  hours  later  the  stomach  was 
empty  but  there  was  a  bismuth  deposit  at  +,  corresponding  to  the  ascending 
duodenum  (cap).  There  was  deformity  of  the  transverse  colon  and  hepatic 
flexure,  the  latter  with  part  of  the  transverse  being  abnormally  distended 
and  evidently  involved  by  some  and  causing  partial  stenosis  below.  The 
descending  colon  was  narrow — probably  congenitally  so. 


Fig.  77. — Stomach  empty  in  six  hours,  but  bismuth  deposit  in  ascending  duo- 
denum at  +.  Hepatic  flexure  enlarged  and  distorted — also  dilated.  Believed  to  be 
drawn  up  by  adhesions,  or  due  to  adhesions  at  angulation  below.  Operation  shows 
thickened  rolled  up  mesenteric  band  adherent  to  duodenum  above  and  upper  surface 
of  hepatic  flexure  below.  Traction  exerted  on  duodenum  causes  lagging  bismuth. 
Weight  of  hepatic  flexure  suspended  from  narrow  thickened  section  of  mesentery  causes 
dilatation.     Small  descending  colon  probably  congenital. 


The  patient  was  referred  to  Dr.  Wm.  P.  Healy  with  the  diagnosis — 
duodenal  ulcer  with  adhesions.  Operation  demonstrated  absolutely  no 
evidence  of  ulaer  or  cicatricial  contraction  from  the  same  and  no  adhesions. 
A  narrow  section  of  the  mesentery  extending  from  the  hepatic  flexure  to 
the  duodenum  (at  the  juncture  of  the  ascending  and  descending  portion) 
was  rolled  up  on  edge  and  thickened  into  a  band  not  circumscribing  but 
by  the  drag,  causing  narrowing  of  and  traction  on  the  cap.  This  ac- 
counted for  local  pain  and  tenderness  and  hypermotility  of  the  stomach. 


METHODS    OF   PHYSICAL   EXAMINATION    OF    THE    STOMACH 


123 


Though  the  traction  was  sufficient  to  produce  delayed  bismuth  deposit 
in  the  cap  at  the  end  of  six  hours,  yet  it  did  not  cause  retention  (gastric) 
at  this  period.  The  mesenteric  thickening  passed  to  the  junction  of  the 
hepatic  flexure  and  transverse  colon  but  did  not  surround  the  gut.  Par- 
ticularly in  the  standing  position  there  would  be  a  painful  drag  on  the 
duodenum,  while  the  colon  contents  would  weight  down  the  flexure  and 
pull  downward  on  the  suspending  band.  The  cause  of  this  condition 
could  not  be  determined  unless  possibly  there  were  mechanical  factors. 
The  patient  was  a  day  laborer — and  in  spite  of  this  very  costive.  The 
hyperacidity  was  probably  reflex.  The  thickened  mesenteric  band  was 
divided  with  subsequent  excellent  results. 

Hour-glass  stomach  can  be  determined  by  means  of  the  x-rays  (Fig. 
78).  The  diagnosis  can  be  made  by  the  methods  described  under  that 
subject,  but  it  is  advisable  to  confirm  the  same  by  Rontgenography  when 
possible. 


;  -  V 

Fig.  78. — Hour-glass  stomach. 

Rontgenography  has  been  recommended  for  the  purpose  of  locating 
the  position  of  the  stomach.  The  method  is  expensive  for  the  patient,  and 
the  diagnosis  can  be  made  by  the  usual  methods  of  physical  examination. 

Even  though  I  have  determined  the  diagnosis  to  be  gastroptosis  by  the 
ordinary  methods,  I  usually  advise  radiography  of  the  stomach  and 
intestines.  The  patient  is  thus  convinced  of  the  correctness  of  the  diagnosis 
and  is  more  amenable  to  treatment. 

Adhesions  if  present  can  also  be  discovered.  For  thoroughness, 
pictures  should  be  taken  in  the  dorsal  and  standing  position.  One  notes 
in  some  cases  a  mass  in  the  pelvis,  in  which  it  is  not  always  possible  to 
determine  adhesions.  Wm.  P.  Healy  suggests  placing  the  patient  for 
five  minutes  in  the  knee-chest  position,  then  turning  case  over  into  the 
Trendelenberg  posture  and  securing  an  additional  radiograph. 

The  gut  will  drop  back  out  of  the  pelvis  and  adhesions  or  stenosis 
will  be  thus  readily  determined.  Radiography  both  confirms  the  diagnosis 
to  the  satisfaction  of  the  patient  and  aids  in  the  prognosis.  If  the  gut  is 
bound  down  by  adhesions,  operative  procedure  is  indicated  in  cases  with 


124 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


obstinate  constipation  of  severe  type,  though  with  slight  adhesions  I  do 
not  advise  operation.     Marked  angulations  are  thus  also  demonstrated. 


I'ig.  79. — Gastroptosis    (water-trap    with 
dilatation.     Radiograph  by  Tousey). 


Fig.  So.- 


-Retention  one  hour  later  (Ra- 
diograph by  Tousey). 


In  Fig.  79  is  shown  a  case  of  gastroptosis.  This  patient  suffered 
from  hypochlorhydria  and  attacks  of  vomiting.  Rose's  belt  and  sub- 
sequently Lane's  belt,  forced  the  stomach  up  sufficiently  so  it  emptied  itself 


Fig.  81. — Shows  marked  enteroptosis 
(prolapse  of  large  intestine.  Radiograph 
by  Tousey) .  Six-hour  residue  in  stomach . 
(Same  case.) 


Fig.  82. — Shows  adhesions  and  sharp  an- 
gulation of  the  transverse  colon  way  down 
in  the  left  side  (Radiograph  by  Tousey). 
(Same  case.) 


quite  well — and  vomiting  ceased.  Patient  refused  operation  for  ad- 
hesions. He  has  gained  weight  and  only  has  occasional  attacks.  The 
types  of  gastroptotic  stomachs  will  be  illustrated  under  Glenard's  Diseases. 


METHODS    OF   PHYSICAL   EXAMINATION    OF    THE    STOMACH 


12: 


The  Diagnosis  of  Carcinoma. — Holzknecht,  Jonas,  Pfahler,  and  Cole 
particularly  advocate  the  value  of  the  .T-rays  for  Ifte  early  diagnosis  of 
carcinoma  of  the  stomach.  Pfahler/  makes  the  following  interesting 
statement:  "Based  upon  a  rather  large  experience  in  the  Rontgen 
diagnosis  of  carcinoma  of  the  stomach,  it  is  my  opinion  that  we  have  in 
this  method  the  most  positive  means  yet  devised  for  the  recognition  of 
carcinoma  in  any  stage  of  the  disease.  It  stands  next  to  an  exploratory 
operation.''  This  last  is  significant.  The  value  of  the  method  of  diagnosis 
depends  on  the  fact  that  carcinoma  of  the  stomach  modifies  the  outline, 
position,  or  lumen  of  the  organ,  or  interferes  with  the  peristaltic  waves,  the 
motility  of  any  part,  or  obstructs  the  passage  of  food.  The  earliest  evidence 
will  be  some  interference  with  the  peristaltic  waves. 

Most  of  our  radiologists  do  not  now  differentiate  between  indurated 
ulcer  and  early  gastric  cancer,  in  which  they  are  wise,  for  the  radiograph 


Fig.  83. — Carcinoma  of  pylorus.  Stomach  is  dilated,  mostly  vertical,  reaching 
to  false  pelvis.  Some  evidence  of  peristalsis  in  walls  of  vertical  part.  The  hori- 
zontal part  extends  to  the  middle  line,  and  ends  with  a  peculiar  serrated  border  (ragged 
edge)  (characteristic  for  carcinoma). 

of  ulcer  and  cancer  near  the  pylorus  may  be  quite  similar.  Syphilitic 
conditions  must  also  be  excluded.  The  Wassermann  test  should  be 
made  in  doubtful  cases.  Holzknecht  holds  that  in  a  patient  with  achylia, 
when  bismuth  residue  is  found  in  the  stomach  six  hours  after  the  meal, 
when  the  head  of  the  bismuth  column  has  reached  the  splenic  flexure 
and  the  second  bismuth  meal  shows  a  normal  stomach  shadow,  the  diag- 
nosis of  early  carcinoma  can  be  made.  This  means  a  hypermotility  of 
the  stomach  with  retention  of  bismuth  and  yet  a  normal  contour  of  the 
stomach  after  the  second  meal.  With  hypermotility  and  yet  retention 
in  the  stomach  there  is  a  change  in  contour  at  the  pyloric  opening  or  in 
the  cap,  i.e.,  some  obstructive  condition  even  though  it  may  be  slight  in 
the  radiograph,  so  Holzknecht's  claim  seems  erroneous. 

The  radiographic  findings  of  carcinoma  depend  on  the  position,  type 
and  form  of  the  growth. 

^Med.  Rec,  March  25,  191 1;  N.  Y.  Med.  Jour.,  May  6,  191 1;  Jour.  .A.mer.  Med. 
Assoc.,  June  17,  1911. 


126 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


I.  Filling  Defects. — A  large  rounded  mass  may  project  into  the  stom- 
ach and  prevent  the  bismuth  from  filling  this  portion.  If  the  body  or 
fundus  of  the  stomach  are  the  part  involved,  obstruction  of  the  pylorus 


Fig.  84. — Gastroptosis.     Hyperperistalsis. 
Patient,  Mrs.  X,  standing. 


Fig.  85. — Hyperperistalsis.     Patient, 
Mrs.  X,  lying  down. 


naturally  does  not  occur.     Absence  of  the  rugae  of  the  stomach  in  the 
involved  area  Cole  believes  an  important  sign  of  malignancy. 

2.  Nodular   growths   infiltrating    the   stomach  walls   show  "finger- 
print" indentations. 


Fig.     86. — Hyjjerperistalsis.      Irregularity 
near  pyloric  orifice.  Cap  well  filled.  Mrs.  X. 


Fig.  87. — Bismuth  retention  in  duodenal 
cap.     Mrs.  X. 


3.  With  an  extensive  destructive  process  an  area  may  be  obliterated 
and  the  edge  of  the  uninvolved  area  appear  serrated  (ragged)  Fig.  83. 

4.  An  annular  growth  may  give  a  funnel  appearance. 


METHODS    OF   PHYSICAL   EXAMINATION    OF    THE    STOMACH 


127 


5.  If  the  pylorus  is  obstructed,  only  a  thin  distorted  line  of  bismuth 
may  be  seen  in  this  region,  or  there  may  be  disappearance  of  the  pyloric 
orifice  with  evidences  of  adhesions,  or  a  worm  eaten  line  of  involvement; 
dilatation  and  stasis  occur. 

6.  With  scirrhous  cancer  the  stomach  may  be  held  up  high  in  position, 
with  disturbance  of  motility  of  the  lesser  curvature. 

7.  Involvement  of  the  pars  media  of  the  stomach  does  not  cause  dila- 
tation.    Sometimes   the  stomach  empties  itself  very  rapidly  in   these 


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Fig.  88. — Normal  umbilicus  lies  at  the  level  of  a  line  drawn  transversely  through  the 
highest  points  of  the  iliac  crests.  Fixed  points  should  be  taken  as  the  basis  of  comparison, 
as  the  umbilicus  varies  in  position,  in  fat  or  flabby  subjects  particularly  between  the 
standing  and  dorsal  postures.  With  the  line  noted  taken  as  the  standard,  the  umbilicus 
and  transverse  colon  are  seen  to  be  slightly  lower  than  normal.  The  arm  of  the  trans- 
verse colon  at  +  is  sharply  angulated  and  held  up  apparently  by  adhesions.  Stomach 
empty  in  6  hours.     Mrs.  X. 

cases,  as  it  does  also  in  early  cases  of  ulcer  (carcinomatous)  near  the 
pylorus  without  interference  (contraction)  to  the  exit  of  contents. 

8.  The  size  and  contour  of  the  deformity  is  constant. 

Case  for  Exploration. — In  Figs.  84-89  an  interesting  case  is  de- 
picted. The  history  is  as  follows:  Female,  aged  57,  first  visit  November 
6, 1914.     Stomach  trouble  since  previous  February,  1914.     Nausea  nearly 


128 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


continuous — vomited  once,  feels  weaker  daily,  very  costive,  soreness  in 
stomach  most  of  the  time,  pain  regularly  half  an  hour  after  meals — 
relieved  some  by  food. 

Residuum  only  few  cubic  centimeters.  Total  acid  6  +  free  HCIO — 
lactic  acid  O,  etc.  Stomach  apparently  emptied  very  rapidly — no  occult 
blood;  believed  at  first  to  be  achylia  gastrica. 


Fig.  89. — Same  patient  after  5  minutes  in  Knee-chest  position — then  turned  over  and 
radiographed  in  Trendelenburg  position — this  combined  method  known  as  Wm.  P. 
Healy's.  Note  the  umbilicus  has  dropped  toward  the  patjent's  thorax  and  to  the  left. 
Taking  the  constant  line  between  the  iliac  crests  (superior)  as  the  level  of  normal 
umbilicus.  We  find  in  Fig.  88  the  transverse  colon  lay  i\i  inches  below  the  line  while 
in  Fig.  89  it  lies  3  inches  above  this  line,  or  j\\i.  inches  change  in  posture.  This  demon- 
strates no  adhesions  bending  the  gut  in  the  pelvis,  but  the  same  narrowing  due  to  probable 
adhesion  is  shown  at  +  in  Fig.  89.      Mrs.  X. 

Stool. — Soaps  and  some  fat  globules  (slight  excess) — few  red  cells 
from  hemorrhoids. 

Physical  Examination. — Slight  epigastric  tenderness.  Lower  border 
stomach  reaches  umbilicus. 

Blood. — Hemoglobin  70  per  cent.,  red  cells  slightly  over  three  million, 
a  quite  marked  secondary  anemia.  Though  this  case  presented  gastric 
findings  of  achylia  gastrica,  she  was  quite  weak,  secondary  anemia 
quite  marked  and  six  to  eight  weeks'  feeding  only  keeps  the  weight  the 
same. 


METHODS    OF    PHYSICAL   EXAMINATION   OF   THE    STOMACH 


129 


Radiographs,  Figs.  84-86,  show  hypermotility — but  stomach  empty  in 
six  hours — ^in  one  picture  some  irregularity  in  the  pyloric  end  of  stomach 
and  cap;  in  two  pictures  lagging  of  bismuth  and  excess  of  same  in  cap — 
and  apparently  adhesions  to  transverse  colon.  The  case  the  writer  believes 
warrants  exploratory  laparotomy.  Adhesions  from  the  transverse  colon  to 
the  duodenum  might  produce  such  deformity  simulating  duodenal  ulcer; 
or  an  ulcer  near  the  pyloric  ring — becoming  malignant  might  be  responsi- 
ble.    No  operation.     Patient  subsequently  died  of  carcinoma  of  stomach.^ 

Fluoroscopy  is  a  most  valuable  feature  of  the  method.  There  is  con- 
siderable danger  in  fluoroscopy  to  the  operator  and  also  to  the  patient, 
unless  in  the  hands  of  an  expert.  The  writer  would  recommend  the  phy- 
sician to  avail  himself  of  the  method  if  he  can  secure  the  services  of  such. 
There  are  many  who  can  take  an  excellent  Rontgenograph,  but  no  great 


Fig.  90. 


-Dilated  duodenal  cap.     Shows  passage  of  bismuth  at  end  of  two  hours. 
Diagnosis  gall-bladder  adhesions  from  stones,  operation  refused. 


number  at  present  writing  qualified  by  experience  to  correctly  interpret 
the  fluoroscopic  appearances  diagnostic  of  early  cancer.  Radiography  is 
therefore  the  most  practical.  In  many  cases,  the  examination  by  the 
ic-ray  cannot  be  carried  out  particularly  in  country  districts  and  a  trip 
to  a  distant  city  is  financially  impossible.  In  suspicious  cases  exploratory 
laparotomy  is  indicated.     I  would  give  this  advice  to  the  country  surgeon. 

Radiography  of  Perigastric  Adhesions — the  Gall-bladder  and  Gall- 
stones.— Cole  has  demonstrated  the  effects  of  adhesions  on  the  peristaltic 
waves  of  the  stomach  cinematographically.  The  lesser  curvature  is 
usually  involved.  Pfahler  shows  that  the  normal  position  of  the  stomach 
and  duodenum  is  modified  by  adhesions  to  the  gall-bladder — in  other 
words,  that  these  organs  are  pulled  upward  and  to  the  right.  With 
chronic  cholelithiasis  and  cholecystitis,  the  swelling  of  the  liver  and  gall- 
bladder brings  them  nearer  the  stomach  and  duodenum,  and  the  peri- 
cystitis leads  to  adhesions.     When  the  swelling  is  reduced,  the  adhesions 

^The  writer  at  the  time  of  the  radiographs  stated  he  believed  carcinomatous  de- 
generation of  an  ulcer  was  commencing  and  suggested  exploration. 
9 


I30 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Fig.  91. — Stomach,  gastroptosis.  Gall-bladder  adhesions,  cap  obliterated.  Only 
small  amount  of  bismuth  meal  retained,  rest  vomited.  Apparent  finger  print  on 
upper  surface  but  angle  quite  acute.  Small  projection  at  inner  edge  of  inner  print. 
No  incisura  opposite  showing  motor  phase.  In  view  of  history  of  case  (inflammation 
of  gall-bladder  with  removal)  and  high  position  of  transverse  colon  on  right  side,  evi- 
dently due  to  adhesion,  distortion  of  stomach  believed  to  be  due  to  inflammatory 
band  of  adhesions.  Cap  moreover  was  obliterated.  This  diagnosis  proved  to  be 
correct  on  operation  by  Wm.  P.  Healy.  A  band  ran  from  stump  of  gall-bladder  to 
the  cap,  with  adhesions  at  angulation  or  lesser  curvature.  The  stomach  was  not  held 
upward  and  transverse  as  is  usual,  but  was  misplaced  in  the  standing  position.  This 
caused  the  patient  severe  pain,  relieved  by  dorsal  posture. 


^  Fig.  92. — Intestines.  Gall-bladder  adhesions.  Transverse  colon  on  right  side 
midway  between  hepatic  flexure  and  umbilicus  drawn  up  in  high  position  -|-.  This 
from  history  of  case  believed  to  be  due  from  adhesions  following  removal  of  gall-bladder. 
Note  the  caput  coli,  ascending  colon,  and  hepatic  flexure  are  low  down  (enteroptosis) 
while  the  transverse  colon  is  held  abnormally  high  by  adhesions.  The  patient  presented 
the  characteristics  of  an  enteroptosis,  diastasis  of  recti  muscles,  etc.  The  transverse 
colon  as  noted  was  found  at  operation,  held  up  at  -f  by  adhesions  from  the  stump 
of  the  excised  gall-bladder.  There  was  a  thin  Jackson's  membrane  on  ascending  colon 
of  which  no  evidence  was  given  by  a;-rays. 


METHODS    OF    PHYSICAL   EXAMINATION    OF   THE    STOMACH 


131 


Fig.  93. — A. — Stomach  in  normal  position,  but  the  liver  and  gall-bladder  swollen 
and  thereby  approaching  more  closely  the  Stomach  and  duodenum,  and  more  easily 
permitting  the  formation  of  adhesions  to  these  organs. 

B. — Liver  and  gall-bladder  returned  to  their  normal  position,  the  stomach  and 
duodenum  drawn  upward  and  to  the  right  by  adhesions  (Pfahler). 


Fig.  94. — -At  +  a  large  bismuth  deposit  in  the  duodenum  showing  it  dilated; 
probably  obstruction  from  adhesions  from  gall-bladder.  No  stones  visible  in 
radiograph.  Indirect  method.  Diagnosis:  Gall-stones,  adhesions  and  chronic  pan- 
creatitis.    Demonstrated  correct  at  operation  by  John  Erdmann. 


132  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

pull  the  stomach  upward  and  to  the  right  (Fig.  93).  In  such  cases  the 
clinical  symptoms  appear  most  marked  during  digestion,  when  the  motor 
unctions  of  the  organs  are  at  their  height,  especially  when  the  emptying 
of  the  stomach  and  gall-bladder  has  been  interfered  with.  Adhesions 
from  gastric  and  duodenal  ulcer  to  the  gall-bladder  or  liver  may  also 
hold  the  stomach  up  more  horizontally — see  adhesions  "under  radio- 
graphic findings  of  gastric  ulcer."  Moreover  from  gall-bladder  adhesions 
the  duodenal  cap  is  often  angulated  and  drawn  more  to  the  right  so  that  its 
lumen  ts  more  horizontal  than  vertical.    The  determination  of  adhesions  show- 


Fig.  95. — At  +  adhesions  near  hepatic  flexure  believed  to  come  from  gall-bladder. 
Same  case  as  Fig.  94.  Gall-stones  and  adhesions  demonstrated  at  operation  by  John 
Erdmann. 

ing  deformity  of  the  cap  or  pylorus,  or  change  in  position  of  the  stomach 
are  often  our  only  positive  radiographic  evidences  of  gall-stones,  or  chole- 
cystitis. This  is  known  as  the  indirect  method.  It  is  estimated  that  only 
in  30  to  50  per  cent,  of  cases  can  gall-stones  be  directly  determined  by  the 
aj-rays  (Fig.  97).  Cholesterin  stones  (Cole),  on  the  other  hand,  cast  a 
negative  shadow,^  a  ring-like  shadow  in  the  bile.  In  Figs.  91  and  92  is 
demonstrated  an  interesting  case.  The  patient,  female,  had  the  gall- 
bladder removed  for  infection.  There  were  many  adhesions  at  that  time. 
She  suffered  from  severe  hyperacidity,  local  tenderness  in  the  epigastrium, 
^American  Journal  of  Roentgenology,  February,  1913. 


METHODS    OF   PHYSICAL    EXAMINATION    OF    THE    STOMACH  1 33 

regurgitation  of  sour  fluid  and  marked  nervous  symptoms.  She  vomited 
occasionally.  Adhesions  were  present  as  demonstrated  in  the  radiographs. 
The  following  case  is  instructive:  male,  aged  57,  two  years  previously 
had  163  gall-stones  removed  from  gall-bladder  which  was  temporarily 
drained,  but  left  in  situ.  Subsequently  epigastric  pains,  looseness  of  the 
bowels,  sometimes  movements  of  putty  color,  tenderness  in  the  epigas- 
trium, no  jaundice,  no  gall-stone  attacks.  Examination  showed  marked 
tenderness  at  Robson's  point  with  some  sensitiveness  in  the  epigastrium. 
The  gall-bladder  was  slightly  sensitive  and  there  was  discomfort  on 
pressure  at  McBurney's  and  Morris'  point. 


Fig.  96. — Patient   with  jaundice  believed   due  to  duodenitis.     Darlc  stripe  in  the 
shadow  of  the  liver  +  +  +  may  indicate  inspissated  bile. 

Gastric  analysis  free  HCl  —  O ;  comb.  HCl  12+;  trace  lactic,  total  acidity 

17  +  . 

Urine — intermittent  glycosuria — no  hile — occassionally  indican. 

Stoo^  showed  excess  of  unabsorbed  fats — excess  of  soap,  and  partly 
undigested  meat,  x-rays  showed  dilated  duodenum  believed  to  be  due  to 
gall-bladder  adhesions — also  adhesions  near  hepatic  flexure  of  colon  (see 
Figs.  94  and  95).  The  writer's  diagnosis  was:  gall-stones,  cholecystitis, 
chronic  pancreatitis,  adhesions  to  duodenum  and  colon — probably  ap- 
pendical  infection.     He  believed  the  achylia  reflex — operation  by  John 


134  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Erdmann  confirmed  these  findings.  In  Fig.  96  is  illustrated  the  findings 
possible  with  inspissated  bile.  The  patient  was  treated  for  inspissated 
bile  and  duodenitis  with  recovery. 

For  preparation  for  the  a;-rays,  it  is  best  two  nights  before  examina- 
tion to  give  a  good  cathartic  with  a  saline  cathartic  the  following  morning, 
and  an  enema  that  night  and  generally  early  in  the  morning  on  the 
day  of  examination.  The  day  before  examination  no  solid  food  of  any 
description  and  no  milk  should  be  taken.  Food  should  consist  only  of 
strained  soups  and  broths.  The  patient  should  appear  for  examination 
with  an  empty  stomach  or  take  a  cup  of  broth.  To  eliminate  spasm  of  the 
pars  pylorica  or  cap,  tinct.  belladonna  gtts.  lot.i.d.  or  atropine  gr.  J^o  t.i.d. 
should  be  given  several  days  before^  and  on  the  morning  of  examination. 
If  there  is  hyperacidity  an  alkali  should  also  be  administered.     Bismuth 


Fig.  97. — Pressure  on  terminal  wave  and  cap  by  four  gall-stones.     Anterior  view. 
Proven  by  surgery.     Direct  Method.     (L.  G.  Cole). 

subnitrate  has  been  generally  abandoned  on  account  of  the  possibility 
of  a  toxic  eflfect,  methemoglobinemia  having  been  reported  as  a  result. 
Bismuth  subcarbonate,  i  ounce  in  a  glass  of  kefir,  fermillac,  or  koumiss, 
is  excellent  for  x-ray  work  or  preferably  barium  sulphate  in  zoolak. 

Bismuth  oxychlorid  may  be  substituted  or  barium  sulphate.  Cole 
and  Einhorn*  have  advocated  radiograms  of  the  digestive  tract  by  in- 
flation with  air,  but  the  author  does  not  believe  the  method  as  satisfactory 
as  by  the  older  technic. 

The  determination  of  gastric  atony  by  a  study  of  the  peristaltic  waves 
{i.e.,  their  absence)  is  interesting  scientifically,  but  simple  methods  only 
are  necessary  for  the  purpose  of  diagnosis. 

RADroM  TRANSILLUMINATION  OF  THE  STOMACH 

This  method  was  first  suggested  by  Einhorn'  with  his  radiodiaphane, 
a  rubber-covered  glass  capsule   containing  0.05  gm.  bromid  of  radium 

^  Some  advise  as  much  as  gtts.  20  belladonna  tinct.  t.i.d. 
2  New  York  Med.  Jour.,  Oct.  8,  1910. 
^Med.  Rec,  July  30,  1904. 


METHODS   OF    PHYSICAL    EXAMINATION    OF   THE    STOMACH  135 

(Curie,  1,000,000  strength  (an  inflating  bulb,  and  using  Kahlbaum's 
fluroscope.  The  transillumination  is  very  faint,  and  the  method  im- 
practical. 

RADroM  PHOTOGRAPHS  OF  THE  STOMACH 

The  same  may  be  said  of  this  procedure  devised  by  Einhorn.* 
The  length  of  exposure  to  radium  is  never  less  than  an  hour  which  is 
decidedly  objectionable,  as  severe  burns  are  possible  from  radium. 

CONCLUSIONS 

The  following  methods  I  have  found  from  experience  to  be  most 
practical  for  general  use. 

Inspection. — By  this  method  the  peculiar  shape  of  the  abdomen, 
suggestive  of  gastroptosis,  can  at  once  be  determined. 

Palpation. — If  movable  kidney  be  present,  it  is  pathognomonic  of 
gastroptosis,  especially  if  the  lower  border  of  the  stomach  lies  abnorm- 
ally low.  Sensitive  areas  can  be  also  determined,  and  often  the  presence 
of  a  tumor. 

Percussion. — The  scratch  method  of  auscultatory  percussion  is 
serviceable  in  mapping  out  the  stomach,  as  is  also  auscultatory  percussion. 

Splashing  Sound. — If  not  present,  it  can  be  artificially  produced, 
and  i?  most  valuable  in  determimng  the  lower  border  of  the  stomach. 

Dehio's  Method. — Additional  water  can  be  given,  if  desired,  and  by 
percussion,  the  observations  determined  by  the  splashing  sound  can  be 
substantiated  for  accuracy. 

Gastrodiaphany. — This  can  be  employed  to  differentiate  in  very  slight 
degrees  of  gastroptosis  between  ptosis  and  dilatation,  and  is  of  value  in 
accurately  mapping  out  the  stomach  before  surgical  operation.  It  is 
useful  for  these  purposes  when  radiography  cannot  be  performed,  as  at 
times  in  country  practice,  and  convinces  the  patient  of  the  presence  of 
ptosis  or  dilatation.  By  it  one  can  at  times  determine  the  presence  of 
a  tumor  at  an  early  stage,  if  on  the  anterior  surface  of  the  stomach. 

Inflation. — This  method,  especially  by  distention  with  carbonic  acid 
gas,  is  an  aid  in  mapping  out  the  stomach  and  in  determining  the  position 
of  the  upper  as  well  as  of  the  lower  border. 

X-Rays. — Are  confirmatory  of  stenosis  or  diverticulum  of  the  esoph- 
agus or  of  the  presence  of  a  foreign  body.  They  will  also  determine 
the  latter  in  the  stomach  and  the  presence  of  hour-glass  stomach.  They 
assist  in  the  determination  of  perigastric  adhesions,  carcinoma,  an  ulcer, 
dilatation  of  the  stomach  with  stenosis,  gastroptosis,  intestinal  misplace- 
ment, angulations,  patency  of  the  ileo-cecal  valve,  adhesions,  stenosis, 
degree  of  intestinal  stasis  and  in  some  cases  the  position  of  the  appendix. 

^  Archives  of  Physiological  Therapy,  Sept.,  1905. 


CHAPTER  VI 
EXAMINATION  OF  THE  FUNCTIONS  OF  THE  STOMACH 

Secretion,  motility,  sensation  and  absorption  constitute  the  functions 
of  the  stomach. 

The  determination  of  the  secretory  and  motor  functions  is  of  impor- 
tance for  accurate  diagnosis.  Examination  of  the  function  of  absorption, 
as  will  be  demonstrated  later,  is  usually  unnecessary. 

The  Function  of  Sensation. — As  a  rule,  under  normal  conditions  we 
do  not  recognize  that  we  have  a  stomach,  unless  for  example  after  the  inges- 
tion of  very  cold,  or  hot  material,  such  as  ice  cream,  very  hot  coffee,  etc., 
on  an  empty  stomach.  Even  so,  the  gastric  sensation  is  evanescent. 
On  the  other  hand  with  a  pathological  condition  of  the  organ,  subjective 
sensations  such  as  cramps,  pain,  burning,  etc.,  may  be  present;  or  even 
a  combined  subjective  and  objective  manifestation  of  sensation  such  as 
tenderness;  which  last  may  be  objective  through  the  manifestation  of 
protective  muscular  rigidity  on  palpation  over  an  ulcer  for  example. 
The  function  of  sensation  may  therefore  be  of  considerable  assistance  to 
our  diagnosis. 

Examination  of  the  Gastric  Secretion  (Secretory  Function). — The 
gastric  secretion  may  occur  under  the  influence  of  the  pleasant  odor  or 
agreeable  appearance  of  the  food  before  ingestion  (psychic  secretion), 
particularly  if  the  subject  has  been  fasting.  It  chiefly  occurs  as 
soon  as  food  enters  the  stomach,  and  continues  until  the  chyme  has 
passed  into  the  intestines.  The  secretion  is  diminished  toward  the  last. 
Examination  at  various  periods  after  taking  food  will  give  different 
results,  and  it  is  necessary  to  examine  the  gastric  contents  at  a  definite 
time  during  the  height  of  digestion.  It  is  desirable  that  a  definite  test- 
meal  should  be  administered. 

TEST-MEALS 

Riegel's  Test-dinner. — Riegel's  test-dinner  is  the  oldest  advocated. 
This  consists  of  a  plate  of  meat  broth  (about  400  c.c.) ;  a  beafsteak  weigh- 
ing from  150  to  200  gm.  (5-7  ounces);  50  gm.  {i^i  ounces)  of  mashed 
potatoes;  and  a  roll  (35  gm.). 

The  average  time  one  should  aspirate  the  stomach-contents  is  about 
four  hours  after  this  meal. 

Ewald's  Test-meal. — This  consists  of  about  6  ounces  (175  gm.)  of 
finely  chopped  meat;  stale  bread,  35  gm.,  and  butter,  to  be  taken  three 
hours  before  withdrawal  of  the  stomach-contents. 

136 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  1 37 

This  is  practical  as  regards  quantity,  as  by  some  the  test-meal  of 
Riegel  is  considered  large  in  amount. 

Test-meal  of  Germain  See. — The  patient  is  given  3  to  5  ounces  (100- 
150  gm.)  of  white  bread;  2  to  3  ounces  (60-80  gm.)  of  finely  chopped 
meat,  and  a  large  glass  (300  c.c.)  of  water,  and  the  contents  examined 
two  hours  later. 

Klemperer's  Test-meal. — This  consists  of  i  pint  (500  c.c.)  of  milk 
and  2  rolls  (70  gm.),  given  on  an  empty  stomach.  Examination  two 
hours  later. 

Test-breakfast  of  Ewald  and  Boas. — This  is  given  in  the  morning  in 
the  fasting  condition,  not  even  water  to  the  allowed,  and  consists  of  i  to 
2  rolls  (35-70  gm.)  and  i  cup  (300-400  c.c.)  of  tea  or  water.  Examina- 
tion one  hour  later. 

The  writer  prefers  two  slices  of  bread  (60  gm.)  and  an  average  of  350 
c.c.  water.  Tea  is  of  unstable  strength,  is  irritating  to  some  patients  and 
colors  the  gastric  contents.  The  average  slice  from  the  loaf  weighes  about 
30  gm.  If  the  patient  is  of  small  physique,  lesser  quantities  may  be 
used.  When  hypermotility  is  present  little  or  no  contents  may  be 
secured  an  hour  after  the  breakfast,  in  which  event  a  new  test-breakfast 
must  be  administered  the  following  morning  and  part  of  the  contents 
asperated  30  minutes  later  and  the  balance  40  to  45  minutes  after  the 
meal.  I  generally  advise  a  full  dinner  the  night  before  at  which 
spinach,  boiled  rice  and  six  raisins  without  seeds  are  taken.  Often  when 
marked  disturbance  of  motility  is  present,  spinach,  etc.,  will  be  found  in 
the  aspirated  contents. 

Fractional  Study  of  Gastric  Digestion  by  Intermittent  Aspiration.^ — 
Rehfuss,  Bergheim  and  Hawk  have  made  a  fractional  study^  of  gastric 
digestion  but  the  writer  sees  no  advantage  in  their  method.  As  a  scientific 
study  the  fractional  method  is  of  value;  for  practical  use,  the  simple 
method  in  vogue  is  sufficient. 

Dry  Test-meal. — Boas  has  suggested  a  dry  test-breakfast,  consisting 
of  a  roll  without  water,  as  giving  a  more  accurate  index  of  gastric  secre- 
tion. In  cases  of  disordered  motility  the  dry  method  is  possibly  more 
accurate,  but  from  a  practical  standpoint  there  is  no  advantage  in  the 
method.  Chace^  reports  a  recent  series.  Some  prefer  it  in  differentiat- 
ing between  hyperacidity  and  hypersecretion. 

Boas'  Test-breakfast. — One  ounce  of  rolled  oats  boiled  in  i  pint  of 
water,  with  salt  to  taste. 

Boas  advocates  this,  as  it  contains  no  lactic  acid,  and  believes  it  should 
be  employed  when  an  accurate  test  for  this  acid  is  desired. 

Two  shredded  wheat  biscuits  with  water  (300  c.c.)  or  a  pint  bowl  of 
granose  have  been  recommended  as  a  convenient  substitute. 

Sahli,  Jaworski,  Friedman,  Roberts  and  others  have  suggested  modi- 
fications.    They  possess  no  advantages. 

The  test-meals  that  are  in  chief  use  are  the  Riegel  test-dinner  and 
Ewald-Boas  test-breakfast.     The  latter  is  easily  procured  and  can  be 

^Journal  A.  M.  A.,  Sept.  12,  1914. 
"Jour.  Amer.  Med.  Assoc,  July  i,  1911. 


138  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

administered  during  office  hours — which  is  the  most  accurate  method. 
It  is  easy  to  recognize  therein  remnants  of  food  from  the  previous  day. 
The  test-dinner  gives  better  results  as  regards  the  investigation  of  the 
microscopic  appearances  and  the  study  of  the  motor  functions.  The 
test-breakfast  in  many  cases  will  be  sufficient,  particularly  by  the  special 
method  described  by  the  author. 

It  is  often  of  service  to  administer  a  special  test-dinner  at  7  p.  m.  and 
the  test-breakfast  in  the  office  at  7.30  to  8.00  a.m.  It  will  be  described 
under  Testing  the  Motor  Functions. 

I  agree  with  Fleiner  that  tea  is  to  some  an  irritant.  In  addition,  it 
is  not  of  stable  strength,  and  water  is  preferable.  The  average  slice  of 
bread  from  the  loaf  weighs  30  gm.  I  employ  usually  two  slices  (60  gm.) 
of  bread  and  300  to  350  c.c.  of  water,  the  latter  by  preference.  One  must 
allow  for  a  patient  of  small  physique  and  poor  nutrition,  for  in  such  cases 
he  cannot  or  will  not  take  this  quantity. 

The  diagnosis  in  most  cases  should  not  be  made  from  a  single  examination 
of  the  gdstric  contents.  Practically  the  specialist  is  often  obliged  to 
make  a  diagnosis  from  one  examination  the  gastric  contents,  stool,  of 
urine,  physical  examination  and  the  radiographs. 

E.  L.  Eggleston^  reports  some  interesting  variations  of  the  gastric 
juice  after  similar  test-breakfasts  in  the  same  patient.  One  should  make 
several  tests  and  take  a  general  average.  In  some  patients  it  would  be 
probably  preferable  to  employ  the  test-dinner  as  well  as  test-breakfast. 
The  gastric  secretion  appetite  juice  is  undoubtedly  greater  after  a 
dinner  of  a  character  agreeable  to  the  patient  than  following  an  unat- 
tractive meal,  consisting  of  bread  and  water.  All  these  factors  must  be 
considered. 

Precautions  before  the  Test  Meal. — Internal  medication  should  be 
stopped  for  at  least  two  days  before  the  test-breakfast  is  administered, 
so  as  not  to  influence  the  result.  This  is  particularly  true  if  acids  or 
alkalis  are  being  administered.  If  the  patient  is  very  nervous  it  is 
preferable  not  to  inform  her  ahead  that  the  stomach  tube  is  to  be 
passed,  as  the  increased  nervousness  might  influence  the  secretion. 

Contradictions  to  Aspiration. — These  are  recent  gastric,  intestinal, 
renal,  bladder  or  pulmonary  hemorrhage,  angina  pectoris,  high  blood 
pressure  in  elderly  persons,  thoracic  aneurism,  active  bronchitis  with 
difficult  breathing,  severe  asthma  and  thoracic  aneurism.  At  least  two 
weeks  should  elapse  after  hemorrhage  before  aspiration  is  attempted.  I 
once  precipitated  a  severe  angina  attack,  fortunately  not  fatal,  when 
attempting  to  pass  the  stomach  tube.  I  also  had  an  unpleasant  experi- 
ence in  a  case  of  endocarditis.  With  poisoning,  however,  all  risks 
should  be  disregarded  and  lavage  should  be  performed. 

When  aspiration  is  contraindicated  the  diagnosis  should  be  made  by 
testing  the  digestive  functions  by  the  Schmidt-Strassburger  diet  and 
then  examining  the  stool  by  the  history  of  the  case  and  by  physical 
examination.  There  are  no  contraindications  to  radiography,  except 
recent  hemorrhage  or  an  acute  condition. 

^  Observations  on  the  Variability  of  the  Gastric  Juice,  New  York  Med.  Jour., 
Oct.  29,  1910. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  1 39 

METHOD  OF  ASPIRATION  OF  THE  GASTRIC  CONTENTS 

The  selection  of  the  proper  type  of  tube  is  important.     It  should  be 
of  soft  rubber,  of  a  caliber  of  30  to  32  French,^  to  alio  wfree  exit  of  contents; 


i 


Z3 


Fig.  98. — Aspirating  tube. 


Fig.  99. — Ewald's  tube. 


Fig.  100. — Correct  position  for  passage  of  aspirating  tube. 

have  an  opening  at  the  tip,  and  one  or  even  two  lateral  openings,  as  in 
Fig.  98  or  the  Ewald  tube  (Fig.  99). 

1  It  may  be  necessary  to  employ  a  tube  of  caliber  26  to  28  French  in  a  patient  of 
small  physique  and  a  still  smaller  tube  for  a  child. 


I40 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Fig.  loi. — Boas'  aspirating  bulb. 


Fig.  I02. — Aspirating  bulb. 


Fig.  103. — Filling  the  bulb. 


EXAMINATION    OF   THE    FUNCTIONS    OF   THE    STOMACH 


141 


Position  of  Patient  and  Operator. — The  patient  sits  upright  on  a 
chair  and  is  protected  by  a  sheet  or  towel.  False  teeth  should  be  re- 
moved. The  operator  stands  in  the  position  as  depicted  in  Fig.  100,  and 
passes  the  tube  along  the  roof  of  the  patient's  mouth.  The  advantages 
of  this  method  are  described  under  Lavage. 

The  tube  should  be  moistened  in  warm  water  and  introduced  about 
20  inches  until  resistance  is  felt,  when  it  should  be  slightly  withdrawn. 
In  the  event  of  gastroptosis  or  dilatation  the  distance  would  be  greater. 
A  PoUtzer  bulb  can  be  employed  for  aspiration. 


Fig.  104. — Second  step  of  aspiration.  ' 

Boas^  Method. — The  Boas  aspirator  (Fig.  loi),  which  consists  of  a 
rubber  bulb  having  two  soft-rubber  ends  and  provided  with  a  clamp,  is 
attached  to  the  stomach-tube  by  a  piece  of  glass  tubing.  The  clamp  is 
fixed,  the  bulb  compressed  and  then  released,  and  thus  filled  up;  the  clamp 
is  opened,  and  the  contents,  by  compression  of  the  bulb,  forced  into  a 
bottle,  glass,  or  some  other  receptacle.  This  is  a  simple  method  of  as- 
piration. Other  devices  with  a  vacuum  bottle,  mouth  suction,  forcing 
air  through  a  double  tube,  etc.,  have  been  suggested,  but  they  are  more 
complicated  and  unnecessary. 

Ewald-Boas  Expression  Method. — This  consists  in  having  the 
patient  exert  pressure  upon  the  stomach  by  means  of  his  abdominal 


142 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


muscles.  He  should  first  inspire  deeply,  and  then  compress  the  abdominal 
walls  in  the  same  manner  as  during  defecation.  The  pressure  expels 
the  gastric  contents  through  the  tube  into  a  receptacle.  This  method  is 
considerably  employed,  and  when  successful,  is  unquestionably  excellent. 
In  cases  of  marked  atony,  both  of  the  stomach  and  abdominal  walls,  in 
excessive  dilatation,  and  at  times  from  plugging  of  the  stomach-tube,  the 
expression  method  is  a  failure. 

Author's  Method. — It  is  my  custom  to  attach  to  the  stomach-tube  a 
bulb  without  valves,  such  as  is  depicted  in  Fig.  102.    The  patient  is  then 


Fig.  105. — Final  step  of  aspiration. 

directed  to  express  the  contents.  If  the  tube  becomes  stopped,  the  thumb 
is  placed  over  the  open  end,  the  bulb  squeezed,  and  the  obstruction  im- 
mediately relieved.  This  obviates  blowing  through  or  removing  the 
tube. 

If  expression  fails,  then  immediate  aspiration  is  resorted  to.  The 
tube  is  pinched  near  the  teeth,  the  bulb  squeezed,  and  the  thumb  placed 
over  the  open  end.  The  stomach-tube  is  then  released,  and  the  vacuum 
in  the  tube  allowed  to  fill  with  gastric  contents,  as  in  Fig.  103. 

When  the  bulb  is  filled,  the  stomach-tube  is  again  pinched,  the  thumb 
removed  from  the  bulb,  and  the  contents  gradually  expressed  into  the 
receiving  vessel,  as  in  Fig.  104. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  143 

The  final  step  is  depicted  in  Fig.  105.  This  process  is  repeated  until 
the  gastric  contents  are  removed. 

EXAMINATION  OF  THE  INGESTA 

Before  chemic  examination  of  the  ingesta  is  begun,  the  quantity 
aspirated  should  be  carefully  measured.  After  the  Ewald-Boas  test- 
breakfast  one  may  expect  to  secure  on  an  average  50  to  75  c.c.  of  contents, 
and  if  100  c.c.  or  more  be  present,  this  would  show  motor  insufficiency. 
A  large  quantity  of  gastric  contents  (350  to  400  c.c.)  four  hours  after  the 
test-dinner  would  determine  it  likewise,  as  described  under  Examination 
of  Motor  Functions.  The  quantity  of  the  residue,  therefore,  has  a  chief 
bearing  on  the  motor  function,  though  in  hypersecretion  abnormal  quan- 
tities are  found.     Reichmann's  test  should  be  made  when  this  is  suspected. 

Macroscopic  inspection  gives  considerable  information.  After  the 
test-breakfast,  in  some  cases  large  undigested  pieces  of  bread  are  brought 
up;  in  others,  remnants  of  bread  that  are  nearly  digested  or  only  slightly 
digested;  and  in  others,  a  fine  fluid  mushy  mass.  These  findings  are  at 
once  suggestive.  With  Riegel's  test-meal  the  differences  are  more 
pronounced;  the  mass  may  be  fine,  uniform,  and  mushy,  containing  no 
coarse  elements;  or  there  may  be  coarse  undigested  meat-fibers. 

Mucus,  blood  (unless  occult),  and  bile  are  readily  visible.  Red  mold 
may  be  mistaken  for  blood  and  green  mold  for  bile.  The  microscope  will 
determine  the  presence  of  mold.  In  some  cases  the  gastric  contents,  when 
placed  in  a  glass  vessel,  forms  three  layers:  at  the  bottom  fine  starchy 
material;  next,  cloudy  fluid;  and  on  top  a  foamy  layer,  which  latter  is 
evidence  of  gaseous  fermentation. 

Chemic  Examination. — The  aspirated  gastric  contents  may  be  filtered 
through  filter-paper.  If  this  is  not  at  hand,  several  layers  of  cheese-cloth 
or  gauze  can  be  employed,  a  simple  and  convenient  method. 

From  a  practical  point  of  view,  the  most  important  feature  to  de- 
termine is  the  content  of  hydrochloric  acid  during  the  height  of  digestion. 
If  free  hydrochloric  acid  be  present,  it  is  then  necessary  to  find  out  whether 
the  secretion  is  normal,  increased,  or  deficient.  If  it  is  deficient  in  amount 
or  absent,  the  digestive  power  of  the  stomach  is  deficient. 

When  free  hydrochloric  acid  is  present,  the  determination  of  pepsin 
is  unnecessary;  in  fact,  it  is  often  present,  even  if  free  hydrochloric  acid 
is  absent.  In  such  event,  if  the  gastric  contents  are  acidified  with  suf- 
ficient hydrochloric  acid  and  digestion  of  albumin  then  occurs,  this  is 
evidence  of  sufficient  pepsin  formation.  In  cases  complicated  by  the 
absence  of  free  hydrochloric  acid  the  examination  for  pepsin  and  rennet 
should  be  carried  out. 

For  a  complete  chemic  analysis  the  following  tests  should  be  performed: 

1.  Reaction. 

2.  Total  acidity. 

3.  Free  hydrochloric  acid. 

4.  Combined  hydrochloric  acid. 

5.  Total  hydrochloric  acid. 


144  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

6.  Lactic  acid. 

7.  Propepton. 

8.  Pepton. 

9.  Pepsin, 

10.  Rennet. 

11.  Dextrin. 

12.  Erythrodextrin. 

13.  Achroodextrin. 

Before  describing  the  tests  it  is  well  to  remember  the  findings  of  the 
normal  gastric  juice  after  the  test-breakfast  for  a  basis  of  comparison. 

Normal  gastric  juice  is  of  acid  reaction;  total  acidity,  40  to  60  (0.15- 
0.21);  free  hydrochloric  acid,  25  to  50  (0.1-0.2  per  cent,  approximately) 
propepton,  small  amount;  pepton  more;  pepsin  and  rennet  present;  sugar 
and  achroodextrin  present;  erythrodextrin  present  in  small  amount  or 
absent;  dextrin  absent. 

Some  patients  may  have  free  hydrochloric  acid  within  the  above 
normal  limits,  and  yet  suffer  from  the  symptoms  of  hyperchlorhydria, 
while  others  may  have  free  hydrochloric  acid  as  high  as  100+  and  present 
no  symptoms  at  all.     Individual  peculiarities  must  be  considered. 

Reaction. — This  is  determined  by  means  of  blue  and  red  litmus- 
paper.  If  the  filtrate  is  acid,  it  turns  the  blue  paper  red;  and  if  alkaline, 
the  red  turns  to  blue;  neutral  gastric  contents  cause  no  change. 

Test  for  Free  Hydrochloric  Acid. — Numerous  coloring-matters 
when  exposed  to  the  action  of  weak  solutions  of  hydrochloric  acid  undergo 
changes,  and  have  been  employed  as  tests  for  its  presence.  Those  that 
are  of  greatest  practical  value  I  will  describe  shortly. 

There  has  been  considerable  dispute  as  to  the  respective  superi- 
ority of  these  tests.  Though  organic  acids,  when  present  in  considerable 
quantities,  may  give  these  color  changes,  yet  they  are  Hot  as  sensitive 
to  organic  acids  as  to  mineral  acids.  I  agree  with  Riegel  that  this  danger 
is  practically  negligible.  As  a  precaution  one  may  employ  one  of  the 
following  qualitative  check  tests,  which  react  only  to  free  mineral  acids 
and  not  to  the  organic  acids. 

In  addition,  the  test  for  lactic  acid  should  be  performed. 

The  Phloroglucin-vanillin  Test  (Giinzburg's). — This  reagent  consists 
of  2  grams  of  phloroglucin  and  i  gram  of  vanillin  dissolved  in  30  grams  of 
absolute  alcohol.  An  equal  number  of  drops,  i  or  2  each,  of  this  and  the 
gastric  juice  are  placed  on  a  porcelain  dish  and  mixed  with  a  glass  rod. 
The  dish  is  then  held  over  an  alcohol  lamp  and  the  fluid  allowed  to  evapo- 
rate slowly.  A  cherry-red  color  appears,  as  in  Fig.  106,  if  free  hydro- 
chloric acid  be  present.  If  there  are  only  traces,  then  there  is  a  rose  tint 
at  the  margin.  If  hydrochloric  acid  is  absent,  the  color  varies  from  yellow 
to  brown. 

This  test  responds  to  free  hydrochloric  acid  and  not  to  organic  acids. 
The  solution  is  unstable,  and  should  be  preserved  in  a  dark  glass  bottle. 
It  is  advisable  to  make  a  fresh  solution  frequently. 

The  Resorcin-sugar  Test  (Boas). — Five  grams  of  resorcin  and  3 
grams  of  cane-sugar  are  dissolved  in  100  c.c.  of  alcohol.     Equal  drops  of 


Fig.  107 


-Resorcin  test, 
reaction. 


Color 


Fig.  106.—  Phloroglucin-vanillin  test. 
Color  reaction. 


A. 

B. 

c. 

5  c.c.Gastric  Juice 

5  c.c.Gastric  Juice 

5  c.c.Gastric  Juice  ^ 

A«i.  too  »on 

PHENOLPHTHALEIH. 

Am  mo  i.Kon 

AUZHRIH. 

AHIDO-BENZOL. 

^"r^l'i,"Z'Z,  T" 

S"^.'n;Ju"."  • " 

TttmATI  OMT1L  THB   UO  TVftS* 

1.  Free  HCL 

2.  Acid  Salts. 

/.  Free  HCI. 

2.  Acid  Salts. 

3.  Organic  Acids. 
4- 

/.  Free  HCL             , 

J.  Organic  Acids. 
4.  Combined  HCI. 

'— -• 

Fig.  108 


Fig.  109. — Phenolphtha 
lein  end-reaction.  Total 
acidity. 


Fig.  III. — Sodium  ali 
zarin  sulphonate  end-re- 
action. 


Fig.  no. — Dimethyl- 
am  ido-azobenzol  end- 
reaction. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  145 

this  reagent  and  gastric  juice  are  slowly  evaporated  to  dryness,  without 
burning,  in  a  porcelain  dish  or  a  butter-dish  over  an  alcohol  flame.  If 
free  hydrochloric  acid  be  present,  a  rose-red  color  appears,  which  fades  on 
cooling  (Fig.  107).  It  responds  to  hydrochloric  acid  only.  It  is  nearly 
as  delicate,  more  easily  obtained,  less  expensive,  and  more  stable  than 
Gunzburg's  test. 

After  performing  one  of  these  check  tests  it  is  preferable  in  all  cases 
to  test  quantitatively  for  acidity;  and  for  this  purpose  I  prefer  Topfer^s 
method. 

The  qualitative  method  gives  no  basis  for  scientific  accuracy. 

Topfer's  Method. — This  method  determines  quantitatively:  Total 
acidity;  free  hydrochloric  acid;  combined  hydrochloric  acid;  total  hy- 
drochloric acid,  and  acid  salts  quite  accurately  for  clinical  purposes.  In 
routine  examinations  it  is  rarely  necessary  to  determine  more  than  total 
acidity  and  free  and  combined  hydrochloric  acid  and  acid  salts.  If  free 
acid  is  absent,  then  the  pepsin  and  rennet  tests  should  be  made.  Occult 
blood  should  be  tested  for  if  ulcer  or  cancer  is  suspected. 

Solutions  Required. — (i)  One  per  cent,  alcoholic  solution  of  phenol- 
phthalein  (colorless). 

(2)  One  per  cent,  aqueous  solution  of  sodium  alizarin  sulphonate 
(opaque  brownish  yellow). 

(3)  Five-tenths  per  cent,  alcoholic  solution  of  dimethyl-amido- 
azobenzol  (yellowish  red). 

(4)  Decinormal  solution  of  NaOH  (sodium  hydroxid)  to  titrate  the 
gastric  juice;  i  c.c.  of  tenth-normal  NaOH  neutralizes  0.00365  hydro- 
chloric acid. 

Topfer's  method  depends  upon  the  different  sensitiveness  of  three- 
color  end-reagents  to  the  various  constituents  of  the  gastric  juice. 

Method. — Though  10  c.c.  of  the  filtrate  are  usually  employed,  I  have 
illustrated  the  method  on  the  basis  of  5  c.c,  as  it  is  often  practically  found 
impossible  to  carry  out  all  the  tests  when  using  larger  quantities.  The 
methods  are  equally  correct. 

In  each  of  the  three  beakers  {A ,  B,  and  C,  Fig.  108)  are  placed  5  c.c.  of 
the  filtered  gastric  contents. 

To  beaker  A  are  added  i  or  2  drops  of  the  phenolphlhalein  solution, 
which  is  used  as  an  indicator  of  the  toted  acidity. 

This  body  turns  red-pink  or  red  as  soon  as  the  fluid  becomes  slightly 
alkaline,  after  the  addition  of  the  sodium  hydroxid. 

To  beaker  C  we  add  i  to  2  drops  of  the  dimethyl-amido-azobenzol  solution. 

A  reddish-pink  or  cherry-red  color  develops  if  free  hydrochloric 
acid  be  present,  depending  on  the  degree  of  acidity.  After  titration 
with  "sodium  hydroxid,  the  end-reaction  is  a  pale  orange  yellow. 

To  beaker  B  is  added  i  or  2  drops  of  the  sodium-alizarin-sulphonate 
solution.  After  suflficient  sodium  hydroxid  is  added,  a  violet  color  (the 
end-reaction)  appears. 

The  titration  with  sodium  hydroxid  is  performed  from  a  graduated 
pipet  or  a  buret,  supported  on  a  stand.  The  latter  should  be  graduated 
to  }4  or,  by  preference,  to  >f  0  c.c. 

The  elements  combining  the  total  acidity  in  beaker  A,  Fig.  108,  are 


146  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

free  hydrochloric  acid,  acid  salts,  combined  hydrochloric  acid  and  organic 
acids,  which  respond  to  the  phenolphthalein  test. 

In  beaker  B  are  free  hydrochloric  acid,  acid  salts,  and  organic  acids, 
responding  to  the  alizarin  test. 

Hence,  as  Topfer  claims,  to  find  the  combined  hydrochloric  acid,  one 
must  subtract  the  acidity  of  B  from  the  total  acidity  of  A . 

In  beaker  C  we  have  free  hydrochloric  acid  alone,  which  responds 
to  the  dimethyl-amido-azobenzol  test. 

In  the  absence  of  organic  acids,  the  acidity  of  C  subtracted  from 
the  acidity  of  B  will  give  the  acid  salts.. 

Total  Acidity. — The  beakers  being  thus  prepared,  titration  of  beaker 
A  (total  acidity)  is  begun  with  the  sodium  hydroxid  solution.  As  this  is 
added,  the  reddish  color  appears,  but  it  disappears  as  the  fluid  is  agitated. 
The  procedure  should  be  continued  until  a  permanent  red-pink  or  reddish 
color  is  present,  as  in  end-reaction  (Fig.  109). 

As  the  degree  of  acidity  is  expressed  by  the  number  of  cubic  centi- 
meters of  a  decinormal  solution  of  sodium  hydroxid  required  to  saturate 
or  make  slightly  alkahne  100  c.c.  of  the  gastric  contents,  and  as  only 
5  c.c.  of  the  latter  was  employed  (which  is  }io  oi  the  total  quantity), 
the  number  of  centimeters  of  the  sodium  hydroxid  necessary  to  produce 
the  end-reaction  must  be  multiplied  by  20. 

Thus  if  3  c.c.  sodium  hydroxid  produced  the  end-reaction  in  5  c.c.  of 
the  filtrate,  the  total  acidity  would  be  3  X  20,  or  60 -|-. 

Multiply  this  figure  of  acidity  by  0.00365,  and  we  have  the  percentage 
of  total  hydrochloric  acid,  or  60  X  0.00365  =  0.219  per  cent. 

Free  Hydrochloric  Acid. — Commence  titration  of  beaker  C,  to  whfch 
the  dimethyl-amido-azobenzol  solution  has  been  added,  and  continue 
titration  until  the  solution  becomes  a  pale  lemon  yellow,  as  in  Fig.  no. 

As  saturation  with  the  decinormal  sodium  hydroxid  solution  was 
computed  on  the  basis  of  100  c.c.  of  gastric  contents,  and  only  5  c.c. 
or  3'^o  were  tested,  the  number  of  cubic  centimeters  of  sodium  hydroxid 
solution  required  to  produce  the  end-reaction  must  be  multiplied  by  20. 
Thus,  if  2  c.c.  of  this  alkaline  solution  will  produce  this  result,  we  must 
multiply  it  by  20,  and  we  say  the  free  hydrochloric  acid  is  40 -f-. 

To  compute  free  hydrochloric  acid  in  percentage,  multiply  40  X 
0.00365  =  0.146  per  cent. 

Combined  Hydrochloric  Acid. — Commence  titration  of  beaker  B,  to 
which  the  sodium-alizarin-sulphonate  has  been  added,  and  continue  the 
process  until  the  end-reaction,  the  violet  color,  as  in  Fig.  in,  occurs. 

As  only  5  c.c.  of  gastric  contents  are  employed,  and  again  the  compu- 
tation is  based  on  100  c.c,  the  number  of  cubic  centimeters  of  decinormal 
sodium  hydroxid  employed  must  be  multiplied  by  20. 

If,  for  example,  2.2  c.c.  were  required,  2.2  X  20  =  44  4-  acidity. 

Topfer  has  shown  that  alizarin  is  sensitive  for  all  the  elements  compris- 
ing acidity,  except  for  the  combined  hydrochloric  acid. 

The  acidity  44,  therefore,  secured  by  this  reaction  must  be  subtracted 
from  60,  the  total  acidity;  and  this  gives  16  acidity  as  the  combined 
hydrochloric  acid. 


EXAMINATION    OF    THE    FUNCTIONS    OF   THE    STOMACH  1 47 

In  percentage  16  X  0.00365  =  0.06  per  cent,  combined  hydrochloric 
acid. 

The  total  acidity,  free  and  combined  hydrochloric  acid,  are  important 
to  examine  for  as  a  matter  of  routine. 

As  fractions  of  a  centimeter  must  often  be  computed,  I  give  an  example 
in  tabulated  form: 

Beaker  A,  5  c.c.  gastric  contents;  for  total  acidity,  3.2  c.c.  decinormal 
sodium  hydroxid  gives  end-reaction. 

Beaker  B,  5  c.c.  gastric  contents;  for  alizarin  test,  2.4  c.c.  decinormal 
sodium  hydroxid  gives  end-reaction. 

Beaker  C,  5  c.c.  gastric  contents;  for  free  hydrochloric  acid,  1.5  c.c. 
decinormal  sodium  hydroxid  gives  end-reaction. 

1.  Total  Acidity.  Beaker  A. — 5  c.c.  X  20  =  100  c.c.  3.2  c.c.  X  20 
=  64  c.c.     64  X  0.00365  =  0.23  per  cent. 

2.  Free  Hydrochloric  Acid.  Beaker  C. — 1.5  c.c.  X  20  =  30  c.c.  30  X 
0.00365  =0.11  per  cent. 

3.  Combined  Hydrochloric  Acid  =  A  —  B. — 

B  =  alizarin  reaction.     A  =  64 
2.4  X  20  =  48.  B  =  48 

A  -  B  =  16  =  combined  HCl. 
16  X  0.00365  =  0.06  per  cent. 

4.  Total  Hydrochloric  Acid,  Free  and  Combined. — o.ii  per  cent.  +  0.06 
per  cent.  =0.17  per  cent. 

5.  Acid  Salts  =  B  —  C  (Organic  Acids  Absent). — 

B  =  48 

C  =  30 

B  -C  =  18 

B  -C  =  18 
18  X  0.00365  =  0.07  per  cent. 

If  10  c.c.  of  gastric  juice  be  employed  in  the  tests,  then  the  number  of 
cubic  centimeters  of  sodium  hydroxid  required  to  produce  the  end-reaction 
must  be  multiplied  by  10. 

If  2  c.c.  of  gastric  juice  is  used,  the  multiple  is  50,  and  so  on. 

Author's  Method. — Simple  Technic  for  Topfers  Method. — In  place  of 
the  buret  or  pipet  for  titration,  the  writer  employs  a  small  measuring 
glass  of  10  c.c.  capacity — marked  each  cubic  centimeter  up  to  ten.  With 
slight  practice,  one  can  easily  estimate  within  }4  c.c. — sufficiently  near  for 
diagnostic  purposes.  One  can  employ  a  centrifuge  glass  marked  in 
cubic  centimeters  and  J-io  c.c.s. — an  excellent  method.  The  gastric  fil- 
trate 5  c.c.  each  is  placed  in  three  small  test-tubes,  Topfers  reagents  added 
to  each  as  usual  and  titration  is  carried  with  the  decinormal  sodium 
hydrate  from  the  small  measuring  glass — drop  by  drop.  This  enables 
the  consultant  to  carry  his  reagents  in  small  compass  and  make  chemical 
tests  on  the  spot. 

When  there  is  a  scanty  amount  of  gastric  filtrate,  after  determination  of 
the  free  hydrochloric  acid,  add  to  the  same  solution,  i  to  2  drops  of  the 
phenolphthalein  solution;  no  change  of  color  is  produced.     Then  titrate 


148  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

with  decinormal  sodium  hydrate  until  the  red  end-reaction  is  reached. 
The  sum  of  the  free  HCl  already  determined  plus  the  amount  of  sodium 
hydrate  required  to  produce  the  end-reaction,  will  give  the  total  acidity. 

The  further  tests  are  as  follows: 

Lactic  Acid. — Ufelmann's  Test. — This  reagent  is  the  one  most  fre- 
quently employed  and  is  sufficiently  accurate,  if  necessary  precautions 
are  observed.  It  should  be  freshly  prepared  before  each  test.  It  can 
be  prepared  as  follows:  10  c.c.  of  a  4  per  cent,  carbolic  acid  solution  is 
mixed  with  20  c.c.  of  distilled  water,  and  to  this  is  added  i  drop  of  sesqui- 
chlorid  of  iron.  A  watery  solution  of  carbolic  acid  (2  per  cent.),  to  which 
is  added  i  drop  of  liquor  ferri  sesquichlorid,  is  another  method  of 
preparation.     These  solutions  have  an  amethyst-blue  color. 

A  simple  method  employed  by  the  writer  is  to  place  a  few  drops  (4  or  5) 
of  carbolic  acid  in  a  test-tube  and  fill  about  two-thirds  with  water.  If  the 
carbolic  is  not  in  perfect  solution,  decant  a  little,  and  add  sufiicient  water 
to  secure  such.  Then  add  a  few  drops  of  liquor  ferri  sesquichlorid,  or 
tincture  iron  chlorid  sufficient  to  give  a  clear  amethyst  color  when  shaken. 
As  about  5  per  cent,  is  the  maximum  solubility  of  carbolic,  the  above 
method  about  corresponds  to  the  per  cent,  methods  described  above. 

Other  methods  of  preparation  are  recommended  by  Riegel:  20  c.c. 
of  distilled  water,  10  c.c.  of  a  4  per  cent,  carbolic  acid  solution,  and  o.i 
c.c.  of  neutral  10  per  cent,  iron  chlorid  solution;  or,  dilute  the  officinal 
iron  chlorid  solution  with  distilled  water  until  the  solution  is  about 
colorless,  and  then  add  a  2  to  4  per  cent,  solution  of  carbolic  until  the 
amethyst-blue  color  appears. 

A  very  dilute  iron  chlorid  solution  will  also  give  the  reaction,  but  the 
blue  color  acts  as  a  contrast. 

The  lactic  acid  reaction  has  been  described  as  a  canary-yellow  or, 
more  often,  a  canary-green  color  (Fig.  112). 

Fatty  acids  produce  an  ash-gray  and  inorganic  acids  decolorize  the 
blue  solution. 

As  at  times  the  phosphates  may  be  present  in  the  gastric  contents 
and  they  give  the  same  reaction,  a  modification  has  been  recommended, 
which  is  practical  for  general  use. 

Modified  Ufelmann. — Take  5  c.c.  of  the  filtrate  plus  10  c.c.  of  ether, 
and  shake  in  a  test-tube  for  a  few  minutes;  then  allow  it  to  stand  until 
the  ethereal  solution  has  separated  from  the  watery  solution.  Pour  the 
ethereal  part  into  another  test-tube  and  place  it  in  a  glass  of  hot  water 
to  evaporate.  Add  i  c.c.  of  distilled  water  to  the  remaining  drops,  and 
test  for  lactic  acid  with  the  Ulfelmann  solution.  If  the  canary  color 
occurs,  lactic  acid  is  positively  shown. 

A  larger  quantity  of  the  filtrate  can  be  employed  with  two  or  three 
times  the  quantity  of  ether.  Fleiner  does  not  evaporate  the  ether,  but 
adds  Uffelmann's  solution  directly  to  it.  The  solution  will  appear  yellow 
at  the  bottom  of  the  tube  if  lactic  acid  be  present. 

Strauss  employs  a  mixing  funnel  with  two  markings,  one  at  5  c.c. 
and  the  second  at  25  c.c.  (Fig.  114). 

Fill  to  5  c.c.  with  the  stomach  filtrate.  Pour  on  ether  (Squibbs') 
up  to  25  c.c.  and  shake  the  mixture  well.     Open  the  lower  stop-cock 


Fi},MI2. 


Fig.  113. 


Fig.  112.- 
Fit(.  ri3- 


-I'fTelmann's  test. 
-ConRo  red  test. 


EXAMINATION  OF  THE  FUNCTIONS  OF  THE  STOMACH 


149 


and  allow  the  fluid  to  run  off'  until  it  reaches  5  c.c,  and  then  pour  in 
distilled  water  to  25  c.c.  To  this  mixture  add  2  drops  of  iron  chlorid 
solution  (i  :g  distilled  water),  and  shake  the  whole. 

Investigations  by  Strauss  show  that  if  one  promillimeter  of  lactic 
acid  be  present,  an  intense  green  color  occurs;  if  less  lactic  acid,  the 
color  is  light  green. 

Arnold^  suggests  a  new  test: 

1.  A  solution  of  gentian  violet  (0.2  c.c.  saturated  alcoholic  solu- 
tion in  500  c.c.  distilled  water),  and — 

2.  Tinctura  ferri  perchloridi,  5  c.c.  (U.  S.  P.),  diluted  with  distilled 
water  (20  c.c). 

A  drop  of  the  iron  solution  gives  a  blue  color  with  i  c.c.  of  the  gentian 
violet,  which  changes  to  yellowish  green  when  gastric 
contents  which  contain  lactic  acid  are  added. 

Other  methods  have  been  suggested,  notably  that 
of  Boas,  which  is  rather  complicated.  It  is  based  on 
the  oxidation  of  lactic  acid  into  acetaldehyd  and  formic 
acid. 

The  presence  of  aldehyd  is  demonstrated  by  the 
iodoform  reaction  with  alkaline  iodin  solution  or  of  al- 
dehyd of  mercury  with  Nessler's  reagent. 

Boas'  Method. — Take  10  to  20  c.c.  of  the  gastric  fil- 
trate and  evaporate  it  into  a  syrupy  consistency  over 
the  water-bath.  If  free  hydrochloric  acid  is  present, 
an  excess  of  barium  carbonate  is  added.  A  few  drops 
of  phosphoric  acid  are  then  mixed  in,  and  the  carbonic 
acid  is  expelled  by  boiling.  The  fluid  is  then  cooled 
and  extracted  two  or  three  times  with  50  c.c,  of  ether. 
After  half  an  hour  pour  off  the  clear  ethereal  layer. 
The  ether  is  now  evaporated,  and  the  residue  washed  in 
a  flask  with  45  c.c.  of  water,  well  shaken  and  filtered. 
Concentrated  sulphuric  acid,  5  c.c.  (sp.  gr.  1.89),  and 
a  pinch  of  manganese  dioxid  are  added  to  the  filtrate. 
The  mixture  is  then  distilled  over  a  small  flame,  and  the 
vapor  conducted  into  a  narrow  cylinder  containing  5  to 
10  c.c.  of  an  alkaline  iodin  solution.  This  consists  of 
equal  parts  of  a  decinormal  iodin  solution  and  the 
standard  potassium  hydroxid  solution.  The  vapor  may 
be  conducted  into  the  same  quantity  of  Nessler's  re- 
agent. If  lactic  acid  is  present,  it  gives  rise  to  the  iodoform  reaction 
(clouding  and  odor  of  iodoform)  with  the  iodin  mixture.  If  Nessler's 
reagent  is  used,  yellowish-red  aldehyd  of  mercury  appears. 

This  procedure  is  further  elaborated  for  the  quantitative  estimation  of 
lactic  acid,  but  it  is  extremely  complicated  and  clinically  unnecessary. 

We  may  say  that  when  a  test-breakfast  or  test-dinner  is  taken  under 
proper  conditions,  only  traces  of  lactic  acid  are  introduced,  and  finding 
it  in  appreciable  quantities  in  the  gastric  contents  is  of  pathologic  significance, 


Fig.  114.— 
Strauss'  mixing 
funnel. 


^  Jour.  Amer.  Med.  Assoc,  1898,  vol.  viii,  p.  21. 


150  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

showing  subacidity  and  stagnation.     It  is  not  pathognomonic  of  cancer, 
but  these  conditions  frequently  exist  in  such  cases. 

Quantitative  Estimation  of  Lactic  Acid. — The  acidity  of  the  filtrate 
is  first  determined;  10  c.c.  of  the  filtrate  are  shaken  up  with  ether  in 
excess.  The  ether  is  then  separated  and  the  degree  of  acidity  computed 
therein. 

Subtract  this  figure  from  the  total  acidity  and  multiply  by  0.09, 
which  gives  the  percentage. 

Volatile  acids  must  be  first  tested  for  and  eliminated  by  boiling. 
This  method  is  only  approximate. 

Volatile  Acids. — Fatty  or  volatile  acids  are  recognized  by  boiling  a 
few  cubic  centimeters  of  the  filtrate  in  a  test-tube.  A  strip  of  moistened 
blue  litmus-paper  is  held  over  the  escaping  vapors.  The  paper  will  turn 
red  if  they  are  present.  Their  quantitative  determination  is  hardly 
necessary. 

Acetic  Acid. — In  large  quantities,  acetic  acid  can  be  detected  by  its 
characteristic  odor.  For  the  detection  of  small  quantities,  Einhorn 
neutralizes  the  watery  residue  of  the  ethereal  extract  of  the  gastric 
filtrate  with  carbonate  of  soda,  and  then  adds  neutral  chlorid  of  iron 
solution,  when  a  red  color  is  developed. 

Propeptone. — Add  to  the  gastric  filtrate  of,  say,  5  c.c,  an  equal 
quantity  of  a  saturated  solution  of  sodium  chlorid.  Propeptone,  if 
present,  is  precipitated.  If  none  is  formed,  then  add  i  or  2  drops  of 
acetic  acid,  and  precipitation  will  occur  if  propeptone  is  present.  On 
heating,  the  solution  clears  up,  but  again  becomes  turbid  on  cooling. 

Peptone.— Preferably,  after  filtering  out  the  propeptone,  take  2  c.c. 
of  the  gastric  filtrate  and  make  strongly  alkaline  by  adding  sodium 
hydroxid  solution  and  then  add  a  few  drops  of  a  weak  i  per  cent,  copper 
solution.     Peptone  gives  a  purple  or  violet-red  color  (biuret  reaction). 

Pepsin. — A  thin  disk  of  the  white  of  a  hard-boiled  egg,  weight  of 
about  I  gram  (i  cm.  in  diameter  and  i  mm.  thick),  is  placed  in  a  test- 
tube  containing  5  c.c.  of  the  gastric  filtrate  and  kept  at  blood  temperature. 
The  tube  can  be  placed  in  water  at  blood  temperature  in  a  Thermos 
bottle. 

If  free  hydrochloric  acid  is  not  present  in  the  filtrate,  add  2  drops 
of  dilute  hydrochloric  acid.  The  presence  of  pepsin  will  cause  dis- 
appearance of  the  albumin  in  from  two  to  six  hours. 

The  methods  for  the  quantitative  determination  of  pepsin  that 
have  been  recognized  as  practical  for  clinical  purposes  are  those  of  Ham- 
mefschlag  and  Mett.  Henry  Illoway^  has  devised  a  simple  method  for 
determining  the  relative  quantity  of  pepsin,  which  seems  to  the  author 
of  value:  10  cgm.,  exact  weight,  egg-albumen  (white  of  hen's  egg)  is 
coagulated  in  the  following  manner: 

The  egg  is  placed  in  a  small  pot  of  cold  water,  which  is  then  covered 
with  a  lid  and  put  on  to  boil.  It  is  allowed  to  cook  for  ten  minutes 
after  the  water  has  begun  to  boil — in  all,  heating  twenty  minutes  from  the 
time  it  has  been  put  on.  The  egg  is  then  taken  out  and  allowed  to  cool, 
either  by  setting  it  in  a  saucer  or  by  putting  it  in  cold  water. 
^  Amer.  Jour.  Med.  Sci.,  .\ug.,  1909. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  151 

To  imitate  the  usual  way,  food  is,  or  should  be,  ingested,  the  segment 
of  albumin  is  divided  into  2  parts.  Observation  has  shown,  as  it  has 
long  been  known  clinically,  that  thus  subdivided  the  gastric  juice  can 
act  upon  it  more  quickly.  The  action  being  from  all  sides,  it  is  more 
effective  when  we  have  eight  sides  for  a  given  quantity  than  where  we 
have  only  four. 

The  coagulated  albumin  is  put  into  lo  c.c.  of  the  gastric  filtrate 
(from  stomach-contents  extracted  one  hour  after  an  Ewald-Boas  test- 
breakfast),  and  this  is  then  placed  in  the  thermostat,  which  is  kept  at 
38°C. 

The  time  in  which  the  10  cgm.  are  digested,  entirely,  partially,  or 
not  at  all,  will  give  us  a  correct  idea  as  to  the  status  of  the  pepsin  secretion 
in  the  case  under  examination,  Illoway,  by  experiments,  shows  that 
normal  digestion  of  the  albumin  requires  from  five  to  five  and  one-half 
hours. 

He  classifies  as  follows: 

Hyperpepsinia. — Digestion  requiring  only  from  three  to  four  hours, 
not  in  any  pathologic  sense  necessarily,  but  only,  to  indicate  a  secretion 
of  pepsin  greater  than  usual,  which  may,  however,  be  the  normal  for  that 
case.  ^ 

Normal  Pepsinia. — Digestion  requiring  from  five  to  five  and  one-half 
hours. 

Hypo  pepsinia. — Digestion  requiring  more  than  the  usual  time.  The 
degree  indicated  by  the  number  of  hours  required  beyond  the  standard 
of  time. 

A  pepsinia. — No  digestion  at  all. 

Jacoby-Solms  Method  to  Determine  Pepsin. — Ricin  Test.^ — Dissolve 
I  gram  of  ricin  in  100  c.c.  of  a  5  per  cent,  solution  of  sodium  chlorid  and 
filter.  Mix  2  c.c.  of  this  filtrate  with  0.5  c.c.  decinormal  HCl  solution; 
I  c.c.  of  diluted  stomach-contents  is  added,  and  allowed  to  remain  at 
blood  temperature  for  three  hours.  Ferments  clear  up  the  ricin  deposit. 
The  quantity  of  pepsin  is  determined  from  the  amount  of  dilution  in 
which  the  stomach-contents  will  cause  the  ricin  deposit  to  disappear. 

Solms  designates  the  amount  of  gastric  juice  which  is  sufficient  to 
clear  up  the  2  c.c.  of  a  2  per  cent,  ricin  solution  in  three  hours,  kept  at 
the  blood  temperature,  as  one  pepsin  unit.  The  normal  stomach-contents 
contain  about  100  pepsin  units  to  the  cubic  centimeter.  Witte'^  has 
modified  the  above  methods. 

Fuld  employs  a  solution  of  edestin  instead  of  ricin.^ 

An  ordinary  Thermos  bottle  partially  filled  with  water  at  a  tempera- 
ture of  about  100 °F.  can  be  employed  in  place  of  a  thermostat,  test-tubes 
containing  the  solutions  being  tightly  corked  and  placed  therein.  Ein- 
horn^  employs  a  Thermos  bottle  with   metal  framework   to  hold  the 

^  "Ueber  eine  neue  Methode  der  quantitative  Pepsinbestimmung  und  ihre  klinsche 
Verwendung,"  Zeitschr.  f.  klin.  Med.,  Bd.  64,  Heft  i  und  2. 

2  Berlin,  klin,  Wochenschr.,  1908,  p.  643. 

3  "Pepsinbestimmung  vermittelst  Edestins,"  MUnch.  med.  Wochenschr.,  1907, 
No.  27,  Vereinsbeilage. 

*  Einhorn,  "A  Simplification  of  the  Jacoby-Solms  Ricin  Method  for  Pepsin  Deter- 
mination," Med.  Record,  Aug.  29,  1908. 


152  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

tubes.  These  last  are  graduated  in  millimeters,  so  as  to  dispense  with 
measuring  glasses. 

Casein  Test. — Gross^  mixes  a  i :  1000  solution  of  casein  containing 
16  c.c.  of  a  25  per  cent.  HCl  to  the  liter  with  the  filtrate  or  its  dilutions, 
and  leaves  it  for  a  quarter  of  an  hour  in  the  thermostat. 

He  then  adds  a  few  drops  of  the  concentrated  solution  of  sodium 
acetate,  which  results  in  a  precipitate  if  the  casein  has  not  been  digested; 
otherwise  the  solution  remains  clear. 

W.  C.  Rose,^  has  devised  a  test  to  be  employed  as  a  substitute  for 
the  "ricin  test,"  employing  a  globulin  preparation  derived  from  the 
ordinary  garden  pea  (Pisum  sativum). 

Mett's  Method. — ^This  consists  in  sucking  fresh  egg-albumen  into 
capillary  tubes  of  i  or  2  mm.  diameter,  coagulating  the  albumin  by 
boiling,  and  then  cutting  off  portions  3  to  5  cm.  long  of  the  filled  tube 
and  adding  these  pieces  to  the  gastric  contents.  This  should  be  kept 
at  body  temperature  for  ten  hours  in  the  incubator.  At  the  end  of  this 
period  each  end  of  the  tube  will  show  a  lack  of  solid  albumin,  owing  to 
digestion,  while  some  will  remain  in  the  central  portion.  Both  the  enipty 
portions  and  the  portion  that  is  full  are  measured,  and  the  activity  of 
the  pepsin  digestion  is  thus  determined.  The  relative  amount  of  pepsin 
varies  according  to  the  square  of  the  length  of  the  empty  portion  of  the 
tube,  the  figures  of  the  latter  being  expressed  in  millimeters;  thus,  3 
mm.  of  digestion  equals  9  parts  of  pepsin;  2  mm.,  4  parts  of  pepsin,  etc. 

Rennet. — Add  5  drops  of  the  filtered  gastric  contents,  preferably 
neutralized  with  decinormal  sodium  hydroxid  solution,  to  10  c.c.  of 
fresh  neutral  milk  in  a  test-tube.  Place  this  in  a  glass  of  warm  water 
at  a  temperature  of  about  ioo°F.,  or  in  a  thermostat.  A  Thermos  bottle 
containing  warm  water  is  extremely  convenient. 

Normal  Rennet. — In  about  five  to  fifteen  minutes  coagulation  will 
occur  if  the  rennet  be  normal.  If  the  same  quantity  of  filtrate  (5  drops) 
be  added  to  20  c.c.  of  milk,  lUoway  finds,  under  normal  conditions, 
coagulation  will  occur  within  fifteen  to  thirty  minutes.  He  suggests 
a  simple  quantitative  method. 

Deficient  Rennet. — ^Add  i  c.c.  of  gastric  filtrate  to  10  c.c.  and  20  c.c. 
of  milk  if  the  smaller  quantity  of  filtrate  (5  drops)  gives  no  result.  If 
reaction  occurs  within  the  same  period,  rennet  is  deficient. 

More  marked  deficiency  when  no  result  is  obtained  with  i  c.c.  of 
gastric  filtrate,  but  is  obtained  within  the  half-hour  with  5  c.c.  of  filtrate. 

Absence  of  Rennet. — When  no  reaction  is  obtained  within  half  an 
hour  with  5  c.c.  of  gastric  juice  and  10  c.c.  of  filtrate,  no  reaction  will 
occur. 

It  has  been  demonstrated  by  Illoway's  experiments  that  rennet 
may  be  present  in  nearly  normal  amount,  even  if  pepsin  is  markedly 
deficient;  it  may  be  present  even  if  pepsin  is  absent. 

Rennet  is  usually  the  last  one  of  the  elements  active  in  the  process  of 
gastric  digestion  to  disappear. 

^  "Die  Wirksamkeit  des  Pepsins  und  eineeinfache  Methode  zuihrerBestimmung," 
Berlin,  klin.  Wochenschr.,  1908,  No.  13,  p.  643. 

2  Arch,  of  Internal  Medicine,  May,  1910,  vol.  5,  pp.  459-465. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  153 

Rennet  Zymogen  {Chyniosinogen). — Add  to  the  same  specimen  of 
milk  3  to  5  drops  of  a  i  per  cent,  solution  of  calcium  chlorid  and  place 
in  an  incubator.  Coagulation  shows  the  presence  of  the  enzyme;  other- 
wise it  is  absent. 

Examination  of  Starch  Digested. — The  salivary  ferment  continues 
its  action  on  starch  in  the  stomach  while  the  amount  of  hydrochloric 
acid  is  not  too  great.  It  is  estimated  that  as  soon  as  the  total  hydro- 
chloric acid  reaches  0.12,  the  action  ceases.  If  the  secretion  of  hydro- 
chloric acid  is  abnormally  great,  starch  digestion  is  soon  stopped,  and 
there  is  either  no  digestion  of  starch  or  the  end-products  are  not  formed. 
The  reverse  is  the  case  in  subacidity. 

To  determine  the  intermediary  stages,  a  dilute  iodin-potassium  solu- 
tion (Lugol's)  is  employed.  It  consists  of  iodin,  o.i;  potassium  iodid, 
0.2;  aqua  destillata,  200.0. 

A  few  drops  of  the  filtered  gastric  juice  are  placed  on  a  porcelain 
dish,  and  to  it  is  added  a  drop  or  two  of  Lugol's  solution.  The  reactions 
are  as  follows: 

Dextrin  turns  the  fluid  blue;  erythrodextrin,  a  red  purple;  achro- 
6  dextrin  discolors  slightly  the  yellow  tincture  of  the  Lugol;  maltose  does 
not  change  the  color. 

For  sugar  or  maltose,  Fehling's  or  Trommer's  test  must  be  employed. 

In  normal  cases,  sugar  and  achroodextrin  are  present;  erythrodextrin 
absent  or  present  in  small  amount;  dextrin  absent. 

If  a  blue  or  blue-violet  color  appear,  saccharification  is  deficient. 

Other  Methods  for  Determining  Free  Hydrochloric  Acid. — It  seems 
advisable  to  describe  a  few  additional  practical  methods  of  determining 
free  hydrochloric  acid: 

1.  Tropdolin  00  (Merck's)  in  a  concentrated  watery  solution  is  recom- 
mended by  Riegel.  Knapp  employs  a  supersaturated  alcoholic  solution 
of  the  same. 

To  5  c.c.  of  the  filtered  chyme  add  2  drops  of  the  tropaolin  solution. 
Free  hydrochloric  acid  turns  it  a  cherry-red.  Titrate  with  decinormal 
sodium  hydroxid  until  it  becomes  amber — the  end-reaction. 

As  5  c.c.  is  ^-io  of  100,  on  which  the  calculation  is  based,  and  if  it 
takes  3  c.c.  of  the  alkali  to  produce  the  end-reaction,  free  hydrochloric 
acid  therefore  =  20  X  3  =  60. 

Multiply  60  X  0.00365  to  secure  percentage. 

2.  Mintz's  Method. — For  example,  to  10  c.c.  of  the  gastric  filtrate, 
decinormal  sodium  hydroxid  is  gradually  added,  until  i  drop  of  the  mix- 
ture no  longer  responds  to  the  Gunzburg  reaction  (phloroglucin-vanillin 
test).     A  platinum  loop  should  be  employed  as  a  drop  carrier. 

The  amount  of  the  sodium  hydroxid  solution  in  this  case  should  be 
multiplied  by  10  to  give  free  hydrochloric  acid. 

For  example,  if  the  reaction  no  longer  appears  after  the  addition  of 
3  c.c.  sodium  hydroxid,  free  hydrochloric  acid  =  30;  percentage  =  30 
X  0.00365,  or  0.109  per  cent. 

3.  Boas  and  Moerner. — -They  estimate  the  free  hydrochloric  acid 
by  Congo  paper,  or  by  a  i  per  cent,  watery  solution  of  Congo  red,  which 
turns  blue  in  the  presence  of  this  acid  (see  reaction,  Fig.  113). 


154  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Take  5  c.c.  of  the  filtrate  and  add  3  or  4  drops  of  the  Congo  red  solu- 
tion.    More  is  unnecessary,  though  Boas  adds  5  c.c.  of  it. 

On  the  other  hand,  Congo  paper  can  be  moistened  in  the  filtrate. 
A  blue  reaction  results  in  each  case, 

Decinormal  sodium  hydroxid  is  then  added  to  the  mixture,  or  the 
paper  is  placed  in  a  porcelain  dish  and  the  alkali  added.  Titration  is 
continued  until  the  blue  begins  to  turn  red.  The  estimation  is  performed 
in  the  same  way  as  before. 

4.  RiegeVs  Method. — Congo  paper  is  employed  in  his  test. 

Take  10  c.c.  of  the  gastric  filtrate.  The  Congo  paper  is  dipped  in 
the  filtrate,  giving  the  blue  reaction  of  free  hydrochloric  acid.  It  is 
then  placed  on  a  saucer.  Decinormal  sodium  hydroxid  is  allowed  to 
drop  slowly  from  the  buret  into  the  filtrate,  and  a  drop  of  the  mixture 
is  removed  from  time  to  time  with  the  platinum  loop  and  applied  to 
the  Congo  paper.  As  the  change  in  color  becomes  indistinct,  this  is 
controlled  by  dropping  distilled  water  on  the  same  piece  of  paper.  The 
alkali  is  dropped  on  the  paper  until  it  begins  to  turn  a  violet  red. 

The  number  of  cubic  centimeters  of  decinormal  sodium  hydroxid 
necessary  to  secure  the  end-reaction,  say,  3  c.c,  is  multiplied  by  10, 
giving  free  hydrochloric  acid  as  30.  This  is  necessary,  as  the  original 
figure  is  computed  for  100  c.c.  of  contents,  and  only  10  c.c.  were  employed. 

To  complete  the  analysis  and  estimate  the  total  acidity,  2  drops  of 
phenolphthalein  solution  are  added  to  the  same  filtrate,  and  titration 
with  the  sodium  hydroxid  is  continued  until  the  color  of  the  solution 
turns  red  (the  end-reaction). 

The  total  acidity  is  indicated  by  the  total  quantity  of  decinormal 
sodium  hydroxid  used  from  the  beginning  of  the  first  titration.  For  ex- 
ample, if  in  both  titrations  6  c.c.  of  sodium  hydroxid  have  been  employed, 
the  total  acidity  is  60,  as  10  c.c.  of  filtrate  were  examined. 

Various  modifications  have  been  employed  for  these  tests,  which 
serve  only  to  confuse  the  reader.     Those  described  are  the  most  practical. 

Small  booklets  of  Congo  paper  can  be  secured  from  Merck.  It 
may  be  prepared  by  saturating  filter-paper  with  a  watery  solution. 
It  is  of  a  reddish-pink  color. 

The  qualitative  examination  for  free  hydrochloric  acid  can  be  made 
with  this  paper  by  dipping  it  into  the  filtered  or  unfiltered  gastric  contents. 
If  free  hydrochloric  acid  is  present,  it  will  turn  blue. 

Determination  of  Hydrochloric  Acid  Deficit. — Honigmann^  and 
von  Noorden-  determine  the  degree  of  hydrochloric  acid  insufficiency 
by  adding  a  decinormal  hydrochloric  acid  solution  to  the  stomach-con- 
tents until  free  hydrochloric  acid  can  be  detected  by  Congo  paper  or 
Gunzburg's  test. 

Ten  c.c.  of  the  filtrate  are  placed  in  a  beaker  and  the  decinormal 
hydrochloric  acid  solution  allowed  to  flow  into  it  gradually,  the  solution 
being  well  mixed.  The  test  being  continued  until  after  repeatedly  dipping 
the  Congo  paper  into  it,  the  paper  shows  a  bluish  tinge. 

The  more  hydrochloric  acid  required  to  secure  the  reaction,  the 
less  the  amount  of  combined  acid  in  the  filtrate. 

'  Berlin,  klin.  Wochenschr.,  1S93,  ^os.  15  and  16. 
*  Ibid.,  No.  19. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  1 55 

Or,  about  25  drops  of  Giinzburg's  solution  can  be  added  to  the  filtrate, 
and  then  titration  with  the  dilute  acid  follows  until  a  red  mirror  appears 
on  a  porcelain  dish  as  a  couple  of  drops  of  this  mixture  are  evaporated 
over  an  alcohol-lamp. 

We  know,  however,  that  the  average  amount  of  combined  hydro- 
chloric acid  is  25,  or  o.i  per  cent.,  under  normal  conditions,  and  Topfer's 
method  of  testing  will  give  the  required  data. 

The  amount  of  peptone  and  propeptone  qualitatively  are  an  indi- 
cation. When  there  is  no  biuret  reaction,  there  will  be  no  combined 
hydrochloric  acid. 

Other  Methods  of  Testing  the  Gastric  Secretion. — There  are  several 
ingenious  methods  for  testing  the  gastric  secretion  in  order  to  obviate  the 
unpleasant  procedure  of  aspiration,  or  because  some  patients  absolutely 
refuse  the  tube,  or  there  is  danger  incurred  from  its  passage,  such  as  in 
cases  of  aneurysm,  angina,  severe  endocarditis,  or  after  a  recent  hemor- 
rhage from  the  stomach  or  lungs,  or  in  the  very  debilitated. 

Sahli's  Desmoid  Test.^ — This  consists  in  placing  methylene-blue 
or  iodoform  in  a  small  rubber  bag  and  tying  it  tightly  with  thin  raw 
catgut.  The  bag  is  swallowed  after  a  large  meal,  and  the  urine  is  ex- 
amined for  methylene-blue,  or  the  saliva  for  iodin.  Methylene-blue 
colors  the  urine  green  or  greenish  blue.  The  iodin  is  tested  for  in  the 
saliva  by  starch-paper  and  fuming  nitric  acid,  giving  a  bluish  or  violet 
color.  It  is  based  on  the  fact  that  raw  connective  tissue,  including 
catgut,  is,  according  to  Schmidt,^  digested  only  by  the  gastric  juice  and 
not  by  the  pancreas. 

The  reaction  occurs  in  healthy  persons  usually  six  to  eight  hours 
after  swallowing  the  bag.  If  it  takes  place  later,  or  not  at  all,  the  secretory 
function  is  insufficient.  An  early  reaction  shows  hyperacidity,  according 
to  Kaliski. 

Einhorn,^  in  some  cases  of  achylia  gastrica  and  cancer,  has  demon- 
strated that  catgut  is  also  digested  in  the  bowel,  and  considers  that 
the  method  is  unsuitable. 

Giinzburg's  Method.^ — This  is  based  on  the  same  principle  as  Sahli's. 
The  patient  swallows  0.2  gm.  potassium  iodid,  inclosed  in  a  small  rubber 
bag,  which  is  tied  with  fibrin  threads. 

After  the  fibrin  is  digested,  the  potassium  iodid  is  set  free  and  ab- 
sorbed. The  test  of  the  saliva  is  made  with  starch-paper  and  fuming 
nitric  acid,  giving  a  violet  or  bluish  color.  This  necessitates  frequent 
examinations  of  the  saliva,  and  the  bag  may  escape  and  the  fibrin  be 
digested  in  the  intestine.  The  objections  are  the  same  as  to  Sahli's 
test. 

Spallanzani's^  sponge  test,  Dunham's*'  thread  test,  Rehfuss's'^  capsule 

1  Correspondenzblatt  fur  Schweizer  Aerzte,  1905,  Xos.  8  and  9. 
-  Deutsch.  med.  Wochenschr.,  1899,  No.  49. 
3  Jour.  Amer.  Med.  Assoc,  May  12,  1906. 

*  Deutsch.  med.  Wochenschr.,  1889,  ^O-  4- 

^  Deutsch.  Arch.  f.  klin.  Med.,  vol.  xxviii,  1881. 

*  New  York  University  Bulletin  of  the  Medical  Sciences,  vol.  i,  No.  4,  p.  178, 
Oct.,  1901. 

^  Journal  A.  M.  A.,  July  11,  1914. 


156  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

test  and  Einhorn's^  stomach  bucket  are  of  no  practical  value  and  not  to 
be  recommended. 

Gas  Fermentation. — The  presence  of  free  hydrochloric  acid  does 
not  prevent  the  development  of  gas.  It  may  occur  in  a  soil  that  is 
non-acid,  together  with  lactic  acid  fermentation.  Stagnation  is  the  chief 
factor  favoring  fermentation.  Various  gases  may  be  formed,  but  from  a 
practical  point  of  view  the  determination  of  their  occurrence,  quantity, 
and  the  time  necessary  for  their  development  are  sufficient. 

The  unfiltered  gastric  contents  should  fill  a  tube  such  as  is  employed 
for  the  determination  of  sugar  in  the  urine  (the  Fiebig  tube).  It  should 
be  placed  in  an  incubator  at  37°C.  (98.6°F.),  or  if  this  is  not  at  hand,  in  a 
uniform  warm  place.  One  can  employ  a  test-tube,  as  suggested  by  Moritz, 
closed  by  a  rubber  cork  through  which  is  passed  a  bent  glass  tube.  The 
test-tube  is  filled  with  gastric  contents  and  then  closed  with  the  cork, 
thus  forcing  some  of  them  into  the  curved  tube  and  preventing  the 
entrance  of  air.     The  apparatus  is  inverted  in  a  beaker. 

As  at  times  the  sugar  may  already  be  destroyed  by  fermentation, 
it  is  well  to  prepare  a  control  tube  of  gastric  contents  to  which  a  small 
quantity  of  powdered  dextrose  has  been  added,  or  it  may  be  added 
at  once.  If  no  development  of  gas  is  noted  after  twenty-four  hours, 
the  tube  should  be  allowed  to  stand  for  three  or  four  days. 

Carbon  dioxid  may  be  identified  by  allowing  a  small  amount  of 
KOH  to  flow  through  a  pipet  to  the  bottom  of  the  gas  column.  The 
carbonic  acid  is  absorbed  by  it  and  the  fluid  moves  up  to  take  the  place 
of  the  absorbed  gas.  The  expressed  test-meal,  or  test-breakfast,  or 
vomitus  can  be  employed. 

If  fermentation  is  excessive,  one  can  assume  motor  insufficiency, 
though  this  should  be  tested  for  by  measuring  the  aspirated  contents. 
If  rapid  fermentation  occurs  within  a  few  hours,  pyloric  stenosis  should 
be  suspected,  as  this  produces  the  most  severe  degree  of  motor  insufficiency 

If  the  stomach  contains  a  large  amount  of  lactic  acid  and  no  free 
hydrochloric  acid,  carcinoma  of  the  pylorus  is  probably  the  cause  of  this 
stenosis. 

Gaseous  fermentation  is  usually  more  intense  in  cases  of  motor  in- 
sufficiency in  which  free  hydrochloric  acid  is  present.  It  can  occur, 
however,  in  any  form  of  stomach  disease  in  which  there  is  a  disturb- 
ance of  gastric  secretion.  Lactic  acid  fermentation  only  occurs  markedly 
in  subacid  conditions.  Alcohol,  various  hydrocarbons,  and  sulphureted 
hydrogen  have  been  found  as  products  of  fermentation.  Boas  finds 
H2S  chiefly  in  benign  ectasia. 

The  determination  of  the  quantity  of  chyme  within  the  stomach  is 
described  under  Testing  the  MotiUty  of  the  Stomach. 

Examination  of  the  Vomit — The  same  methods  that  are  employed 
in  examination  after  the  test-meal  apply  to  investigation  of  the  vomitus. 
The  information,  however,  is  not  as  positive,  as  the  admixture  of  bile, 
saliva,  etc.,  obscures  the  result.  Important  information  is  secured,  but 
the  physician  should  inspect  the  vomitus  in  person. 

If  the  vomitmg  consists  chiefly  of  food,  it  should  be  learned  when 
^  Medical  Record,  July,  1890. 


EXAMINATION   OF   THE   FUNCTIONS    OF    THE    STOMACH  1 57 

the  last  meal  was  taken  and  of  what  it  consisted.  If  coarse  morsels 
are  found  six  or  seven  hours  after  a  meal,  the  conclusions  are  naturally 
different  than  if  they  were  found  directly  after  eating;  and  by  this  means 
we  can  often  determine  the  digestive  and  motor  powers  of  the  patient. 

If  food  is  vomited  that  was  ingested  the  day  before,  marked  motor 
insufficiency  is  present. 

With  gastric  ulcer,  vomiting  often  occurs  at  the  height  of  digestion. 
In  some  nervous  diseases  it  usually  takes  place  immediately  after  eating. 
With  ectasia,  vomiting  occurs  late  in  digestion  and  often  in  great  quantity. 

In  dilatation  with  hypersecretion  the  fluid  is  abundant,  and  there 
are  fine  remnants  of  amylaceous  material;  while  with  carcinoma  of  the 
pylorus  undigested  morsels  of  meat  are  present.  In  the  former  case  free 
hydrochloric  acid  is  present,  and  Congo  paper  will  turn  blue;  in  the 
latter  case,  no  color  change  occurs. 

The  presence  of  blood  is  important,  and  its  appearance  depends 
on  the  presence  or  absence  of  hydrochloric  acid,  on  the  rapidity  with 
which  it  is  poured  forth,  and  on  the  length  of  time  it  has  remained  in 
the  stomach.  It  may,  therefore,  appear  chocolate  brown,  like  cofifee- 
grounds,  or  as  fresh  blood. 

Mucus  is  also  readily  discovered.  Pus  is  rarely  found,  unless  from 
perforation  in  phlegmonous  gastritis,  or  from  some  neighboring  focus 
into  the  stomach,  or  unless  it  has  been  swallowed.  Microscopic  pus 
occurs  with  ulceration. 

During  violent  vomiting  bile  is  frequently  in  evidence,  or  when 
vomiting  occurs  on  an  empty  stomach.  It  may  occur  with  pyloric 
stenosis,  when  the  opening  is  kept  slightly  patent.  With  persistent 
vomiting  of  bile  one  would  suspect  some  obstruction  of  the  duodenum, 
such  as  carcinoma,  torsion,  gall-stones,  etc. 

Parasites,  such  as  ascarides  or  the  oxyuris  vermicularis,  are  occa- 
sionally found  in  the  vomit,  and  very  rarely  a  piece  of  gastric  tumor. 

Examination  of  the  Contents  of  the  Fasting  Stomach. — It  may  be 
necessary  to  investigate  the  contents  of  the  fasting  stomach,  especially 
when  disturbance  of  the  motor  function  is  present  or  when  hypersecretion 
is  suspected.  Under  normal  conditions  one  might  expect  to  find  from  5 
to  even  15  c.c.  of  gastric  contents  in  the  normal  stomach.  Anything 
over  20  c.c.  to  30  c.c.  is  considered  pathologic,  when  there  are  gastric 
symptoms. 

The  examination  should  be  made  in  all  cases,  where  one  suspects 
an  abnormal  quantity  of  gastric  contents  will  be  found  in  the  morning 
after  fasting;  also  in  all  cases  of  suspected  ectasia  or  atony  of  the  stomach. 

The  best  method  is  to  wash  the  stomach  thoroughly  the  night  before, 
both  in  the  sitting  and  reclining  posture,  and  then  administer  a  test- 
supper.  The  contents  are  aspirated,  measured,  and  examined  the 
following  morning  before  breakfast.  The  chief  purpose  is  to  test  the 
motor  function  of  the  organ,  especially  to  determine  whether  motor 
insufficiency  of  a  high  degree  is  present. 

Reichmann's  Method. — When  hypersecretion  is  suspected,  the  pro- 
cedure is  slightly  different.  The  stomach  is  thoroughly  washed  at  about 
10  p.  M.  and  care  taken  that  all  the  water  is  removed.     No  food  or  drink 


158  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

is  allowed  thereafter,  and  in  the  morning  before  breakfast  the  contents 
are  aspirated  and  examined.  A  quantity  over  20  ex.  to  30  c.c.  found  re- 
peatedly I  would  consider  pathologic  (hypersecretion),  when  there  are 
symptoms. 

When  there  is  permanent  regurgitation  of  bile  into  the  stomach, 
Riegel  has  shown  that  this  method  of  examination  is  important.  If 
bile  and  pancreatic  juice  enter  the  stomach,  digestive  processes  are 
arrested. 

Bile,  pancreatic,  and  probably  intestinal  juice  are  occasionally  found 
in  the  empty  stomach  (duodenal  juice,  Boas).  This  material  is  grass 
green  or  yellowish,  containing  bile  constituents,  and  converts  starch 
into  maltose  and  dextrose,  proteins  into  peptones,  and  splits  fats.  If 
it  is  aspirated  occasionally,  it  is  probably  not  significant;  but  if  there  is 
constant  regurgitation,  it  is  suggestive  of  obstruction  in  the  duodenum. 

When  there  is  obstruction  to  the  flow  of  the  intestinal  contents, 
or  a  communication  between  the  stomach  and  intestine,  intestinal  contents 
are  found  in  the  stomach. 

ABNORMAL  CONSTITUENTS  OF  THE  STOMACH-CONTENTS 

Abnormal  products  which  are  of  importance  for  our  diagnosis  are 
quite  frequently  found  in  the  gastric  contents.  They  may  contain 
mucus,  blood,  bile,  intestinal  juice,  and  pus. 

Mucus  when  present  in  considerable  quantity  is  easily  recognized.  It 
generally  occupies  the  upper  part  of  the  fluid,  appearing  in  swollen, 
glassy  lumps  or  in  flakes  and  shreds.  It  is  also  intimately  mixed  with 
the  food.  It  can  be  readily  lifted  with  a  glass  rod.  If  in  small  amount, 
a  few  drops  of  dilute  acetic  acid  are  added,  it  will  be  revealed  by  the 
characteristic  precipitate. 

Bile  and  Intestinal  Juice. — Small  quantities  of  bile  and  intestinal 
juice  may  occasionally  be  met  with  normally.  In  the  paragraph  on 
"Examination  of  the  Contents  of  the  Stomach  after  Fasting"  I  referred 
to  the  presence  of  bile  and  intestinal  juice,  and  that  their  frequent  oc- 
currence is  due  either  to  relaxation  of  the  pylorus  or  stenosis  of  the 
duodenum  below  the  mouth  of  the  bile-duct.  Pure  bile  is  golden  yellow, 
but  green  if  mixed  with  gastric  juice.  I  believe  that  too  often  the  diag- 
nosis is  made  by  simple  inspection.  Mold  may  produce  a  greenish  color, 
and  I  have  found  it  on  several  occasions.  For  accuracy,  the  tests  should 
be  made — Gmelin's  for  bile-pigment,  and  Pettenkofer's  for  bile-acids. 

Einhorn  suggests  the  following  tests  for  the  intestinal  juice,  which  is 
recognized  by  its  ferments,  trypsin,  amylopsin,  and  steapsin: 

Trypsin. — Mix  the  filtrate  with  i  per  cent,  solution  of  sodium  carbonate 
until  the  reaction  is  decidedly  alkaUne;  add  a  flake  of  fibrin  and  keep 
in  a  warm  place  for  several  hours.     Trypsin  will  dissolve  the  fibrin. 

Amylopsin. — Starch  is  changed  into  maltose. 

Steapsin. — Add  i  drop  of  blue  litmus  tincture  and  a  few  cubic  cen- 
timeters of  the  neutralized  filtrate  to  a  small  portion  of  milk  and  keep 
it  at  blood  temperature.  Steapsin  changes  the  blue  color,  and  the  milk 
becomes  slightly  reddish  from  decomposition  of  the  fat  into  fatty  acids. 


EXAMINATION    DF    THE    FUNCTIONS    OF    THE    STOMACH  1 59 

Blood. — Blood  in  large  quantities  is  easily  recognized,  as  is  fresh 
blood,  even  if  in  small  amounts. 

Fresh  blood  mixed  with  gastric  contents  presents  a  reddish  appear- 
ance, while  old  blood  is  brownish  or  of  a  coffee-ground  color.  It  may- 
even  appear  blackish.  When  the  blood  cannot  be  detected  microscopically 
and  gastric  hemorrhage  is  suspected,  occult  blood  must  be  examined  for. 

It  is  advisable  to  make  the  same  examination  of  the  stool. 

I.  Benzidin  Blood  Test  for  Gastric  Contents  and  Stool. — This  is  a 
test  devised  by  O.  and  R.  Adler.^  They  first  applied  it  to  test  the  feces. 
Schlesinger  and  Holst^  advise  boiling  the  gastric  filtrate  and  testing  in 
the  same  manner  as  for  feces. 

Gastric  Contents. — Solution  i. — Knifepointful  of  benzidin  (Merck's) 
is  added  to  2  c.c.  of  glacial  acetic  acid  and  allowed  to  stand  and  dissolve. 

Solution  2. — Ten  to  12  drops  of  the  benzidin  solution  are  added 
to  2>^  or  3  c.c.  of  a  3  per  cent,  peroxid  of  hydrogen  solution. 

Three  or  4  drops  of  the  gastric  filtrate,  which  has  been  boiled  for 
about  half  a  minute,  are  added  to  Solution  2.  In  the  presence  of  blood, 
a  green  or  blue  color  results  in  from  a  few  seconds  to  a  minute. 

Stool. — The  stool  should  also  be  examined. — A  small  piece  of  feces 
about  the  size  of  a  pea  is  mixed  with  2  c.c.  of  water  and  boiled  in  a  test- 
tube  closed  with  cotton  for  half  a  minute;  3  or  4  drops  of  the  boiled  fecal 
solution  are  added  to  Solution  2.  A  green  or  blue  color  results  if  blood 
be  present. 

For  making  this  test  Paul  Cohnheim  has  devised  a  slight  modifica- 
tion. Place  a  little  benzidin  (Merck)  in  a  dry  test-tube  and  shake  it 
with  about  >^  c.c.  of  glacial  acetic  acid;  add  2  c.c.  of  H2O2  and  then  care- 
fully place  on  its  surface  a  little  of  the  fluid  which  is  to  be  examined. 
The  last  should  be  previously  boiled.  A  green-tinted  ring  results.  The 
intensity  of  the  green  or  bluish  ring  affords  one  conclusions  as  to  the 
quality  of  the  occult  blood. 

Benzidin  Test  Paper. — Einhorn^  has  devised  a  benzidin  testing  paper 
as  follows: 

Take  a  saturated  solution  of  benzidin  and  glacial  acetic  acid;  moisten 
filter-paper  therein  and  dry  it.  Both  in  preparing  the  paper  and  making 
the  test  avoid  contact  with  the  fingers,  as  a  drop  of  perspiration  causes 
the  reaction.  When  handling  the  paper,  employ  ivory-tipped  forceps 
or  protect  the  hand  by  a  towel. 

Method. — Gastric  Contents. — A  piece  of  benzidin  paper  is  first  im- 
mersed in  the  gastric  filtrate,  and  then  a  few  drops  of  hydrogen  peroxid 
are  added.  The  paper  is  then  placed  on  a  piece  of  white  porcelain  and 
examined  for  the  development  of  a  blue  color.  If  blood  is  present,  a 
blue  or  green  color  occurs  in  a  few  seconds  to  a  minute.  Einhorn  shows 
that  if  we  wait  longer  periods,  other  substances  may  cause  the  reaction, 
also  in  time  the  paper  moistened  with  peroxid  will  become  blue. 

Feces. — In  testing  for  occult  feces  with  the  paper,  a  small  piece  the 
size  of  a  pea  is  rubbed  up  with  2  c.c.  of  water,  the  benzidin  paper  im- 

*  Zeitschr.  fiir  physiol.  Chemie,  Bd.  41,  Heft  i  and  2,  p.  59. 
^  Deutsch.  med.  Wochenschr.,  iqo6,  No.  36,  p.  1444. 
3  "A  New  Blood  Test,"  Med.  Record,  June  8,  1907. 


l6o  DISEASES    OF   THE    STOMACH   AND  INTESTINES 

mersed  therein,  a  drop  of  hydrogen  peroxid  added,  and  the  blue  color 
then  examined  for. 

The  benzidin  paper  Einhorn  recommends  as  a  preliminary,  and 
if  there  is  immediately  a  strong  reaction  or  none  at  all,  he  regards  the 
result  as  reliable.  If  at  the  end  of  a  minute  only  a  trace  of  reaction 
occurs,  then  the  aloin-ether  extract  method  may  be  employed  as  a  check. 

In  the  fecal  examination,  ether  extract  of  feces,  as  employed  in  the 
aloin  test,  makes  the  benzidin  test  more  reliable. 

In  examination  of  the  gastric  contents  no  meat  products  or  iron  prepa- 
rations should  be  taken  for  at  least  twenty-four  hours  before  the  test,  and 
in  testing  the  stool  the  same  rule  must  he  observed;  but,  preferably,  for  a 
longer  period  if  possible — at  least  two  or  three  days  as  a  precautionary 
measure.  It  has  been  demonstrated  that  prunes  give  the  typical  reaction 
and  that  rice,  milk,  and  potatoes  react  to  it. 

2.  Phenolphthalein  Test  for  Occult  Gastro-intestinal  Hemorrhage. — 
The  reagent^  is  made  as  follows:  Dissolve  i  gm.  of  phenolphthalein  and 
25  gm.  of  potassium  hydroxid  in  100  c.c.  of  water,  and  reducing  with  10 
gm.  of  pulverized  zinc.  The  resulting  red  fluid  is  stirred  or  shaken 
over  a  small  flame  until  it  is  entirely  decolored,  the  phenolphthalein  being 
reduced  to  phenolphthalin.  The  solution  is  then  filtered,  when  it  is 
ready  for  use.     It  keeps  indefinitely. 

A  small  amount  of  the  stool,  about  5  c.t.  is  rubbed  up  in  water  until 
it  forms  a  thin  fluid.  Into  this  a  little  glacial  acetic  acid  is  stirred  to 
acidify,  ether  is  then  added  in  equal  volume,  and  the  containing  glass  is 
slowly  moved  to  and  fro  until  the  contents  are  well  mixed.  The  ethereal 
solution  is  then  decanted  into  another  reagent  glass  and  20  drops  of  the 
phenolphthalin  reagent  are  added.  This  last  is  shaken,  and  then  3  or 
4  drops  of  hydrogen  dioxid  are  added.  In  the  presence  of  blood  the 
phenolphthalin  is  oxidized  into  phenolphthalein,  and  as  it  is  in  alkaline 
medium,  the  fluid  turns  pink.  With  considerable  blood  the  pink  tint 
persists  for  some  time;  with  little  blood,  it  soon  fades.  With  much 
blood,  the  reaction  is  pronounced,  even  without  the  hydrogen  dioxid. 
To  test  the  stomach-contents,  a  few  drops  of  glacial  acetic  acid  are  added 
to  a  few  cubic  centimeters  of  gastric  filtrate  and  the  same  methods  followed. 

3.  Weber's^  Modification  of  Van  Deen's  Test  for  Occult  Blood. — 
Dilute  the  stomach-contents  or,  preferably,  the  filtrate  thereof,  with  one- 
third  volume  of  glacial  acetic  acid,  and  extract  with  about  10  c.c.  of 
ether.  A  few  cubic  centimeters  of  this  acid  ether  extract  are  mixed  with 
10  drops  of  tincture  of  guaiac  and  20  to  30  drops  of  ozonized  oil  of 
turpentine  (old  turpentine  exposed  to  air). 

If  blood  is  present,  the  mixture  turns  a  blue  or  blue  violet;  if  absent, 
it  turns  a  reddish  brown  with  a  green  tinge.  The  reaction  is  more  distinct 
if  a  little  water  is  added  and  the  blue  pigment  extracted  with  chloroform. 

Many  authors  insist  that  the  tincture  of  guaiac  should  be  freshly 
prepared  on  each  occasion.  Soper^  demonstrates  that  this  is  unnecessary. 
He  reduces  the  guaiac  resin  in  a  mortar  to  a  fine  powder,  slowly  adding 

^  Boas  believes  this  method  the  best.  Deutsche  med.  Wochenschr.,  Berlin,  Jan. 
12,  191 1,  vol.  xxxvii,  No.  2. 

*Berl.  klin.  Wochenschr.,  1893,  No.  19. 
'Jour.  Amer.  Med.  Assoc,  Jan.  28,  1911. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  l6l 

95  per  cent,  alcohol,  leaving  a  residuum  of  guaiac  in  the  mortar  to  insure 
a  strong  tincture.  This  is  filtered  and  kept  in  a  glass-stoppered  bottle 
as  a  stock  preparation.  Dilute  a  portion  of  this  stock  tincture  with  95 
per  cent,  alcohol  (tincture,  i  part;  alcohol,  5  parts),  and  keep  in  a  smaller 
glass-stoppered  bottle  for  daily  use. 

The  Stool. — The  test  for  occult  blood  is  as  follows: 

Treat  5  c.c.  of  feces  with  20  c.c.  of  ether;  the  latter  is  then  poured 
off;  2  c.c.  of  glacial  acetic  acid  are  added  to  the  feces  and  thoroughly 
stirred.  This  mixture  is  again  treated  with  about  10  c.c.  of  ether  and 
allowed  to  separate. 

To  2  c.c.  of  the  etherized  extract  add  2  or  3  drops  of  a  fresh  tincture 
of  guaiac.  Then  add  20  to  30  drops  of  ozonized  oil  of  turpentine,  or 
pure  hydrogen  dioxid,  and  shake  well.  If  blood  be  present,  there  appears 
a  blue  or  blue-violet  color. 

Meat  and  iron  preparations  should  be  avoided  for  from  twenty-four 
to  seventy-two  hours  before  these  tests. 

4.  Kiiinge's  Aloin  Test. — Feces. — In  this  test  freshly  prepared  aloin 
is  employed.     Dissolve  as  much  aloin  as  can  be  placed  on  the  tip  of  a 


Fig-   IIS- — Teichmann's  hemin  crystals  (Jakob). 

knife-blade  in  10  c.c.  pf  70  per  cent,  alcohol;  add  2  c.c.  of  the  aloin  solu- 
tion to  2  c.c.  of  the  ethereal  extract  of  feces,  prepared  as  above,  and  then 
the  oil  of  turpentine  or  dioxid  of  hydrogen  as  described.  A  cherry-red 
color  appears  in  the  fluid  if  blood  be  present. 

Gastric  Contents. — Ethereal  extract  of  the  filtrate  is  prepared  as 
in  Weber's  test.  The  rest  of  the  test  is  the  same  as  the  aloin  test  of 
feces. 

Einhorn  at  times  employs  aloin  paper  prepared  with  filter-paper 
saturated  with  a  solution  of  aloin  in  70  per  cent,  alcohol,  the  paper  being 
then  dried  for  future  use. 

Iron  Test. — This  is  useful  if  the  patient  is  not  taking  iron.  Place  a 
small  amount  of  unfiltered  gastric  contents  in  a  porcelain  dish.  Add  to  it 
a  pinch  of  potassium  chlorid  and  a  few  drops  of  concentrated  hydrochloric 
acid.  Mix  these  thoroughly.  Then  heat  over  a  small  alcohol  flame  until 
a  dry  residue  is  secured.     Add  to  this  a  few  drops  of  a  weak  solution  of 


l62  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

potassium  ferrocyanid.  If  blood  is  present,  a  Prussian  blue  color  results. 
I  prefer  the  benzidin  or  Weber's  test. 

The  spectroscopic  test — Heller's,  Schonbein's,  Korcznski's,  the  hemin 
test,  etc. — have  been  suggested,  but  the  ones  described  are  the  most 
practical. 

Hemin  Crystals. — Hematin  combines  with  one  molecule  of  hydro- 
chloric acid  to  form  hemin.  This  last  substance  crystallizes  in  brown 
plates  or  columns,  and  when  produced  by  the  addition  of  glacial  acetic 
acid,  may  be  of  considerable  size.  Star  or  rosette-shaped  crystals  may 
also  be  present.  The  formation  of  hemin  may  occur  from  mere  traces  of 
blood.     Negative  results  are  not  conclusive. 

The  test  is  as  follows:  Evaporate  a  small  sample  of  gastric  filtrate 
on  a  watch-crystal  over  a  small  alcohol  flame.  Scratch  the  residue 
free,  and  mix  with  it  a  grain  or  two  of  finely  powdered  salt.  Transfer 
this  to  a  microscopic  slide,  and  add  a  drop  or  two  of  glacial  acetic  acid. 


Fig.  ii6. — Crystals  of  hydriodic  hematin  ester  (Gross). 

Gently  heat  the  slide  for  a  minute  or  two  until  bubbles  begin  to  form, 
then  cool  it  off  and  examine  under  the  microscope  with  a  one-sixth  or 
one-seventh  objective.     The  crystals  will  be  seen  as  in  Fig.  115. 

Gross^  employs  Stozyzowski's  modification  of  the  above  (Teich- 
mann's)^  method.  He  recommends  it  particularly  in  the  determina- 
tion of  blood  in  suspected  duodenal  ulcer,  first  obtaining  the  duodenal 
contents  by  his  aspirator.  He  notes  small  apparent  blood  points  in 
the  contents,  and  placing  one  of  these  on  a  slide,  drying  it  slightly,  then 
covers  it  with  a  cover-glass.  At  the  margin  he  places  i  or  2  drops 
of  the  following  mixture:  alcohol,  water,  glacial  acetic  acid,  of  each, 
I  c.c,  and  3  drops  of  hydriodic  acid  (undecomposed,  if  possible,  and  of  a 
specific  gravity  of  1.5).  The  specimen  surrounded  by  this  solution  is 
boiled  for  about  ten  seconds  over  a  small  spirit  lamp.  The  loss  sustained 
by  evaporation  should  be  constantly  replaced.     Objective  7,  ocular  3, 

^  New  York  Med.  Record,  April  22,  191 1. 
"^  Therap.  Monatsh.,  Sept.,  1902. 


EXAMINATION    OF    THE    FUNCTIONS    OF    THE    STOMACH  1 63 

should  be  employed  in  the  microscope.  If  the  specimen  is  blood,  there 
will  be  rhomboid  prismatic  crystals  of  a  black  color  (hydriodic  hematin 
ester),  as  in  Fig.  ii6. 

Pus  is  seldom  found  in  the  gastric  contents,  and  is  recognized  readily 
under  the  microscope.  Excluding  ingested  pus  and  phlegmonous  gastritis, 
pus  shows  ulceration  of  the  gastric  mucosa. 

MICROSCOPIC  EXAMINATION  OF  THE  GASTRIC  CONTENTS 

The  relative  value  of  the  microscopic  examination  of  the  gastric 
contents  after  the  test-meal,  of  the  vomitus,  and  of  the  fasting  stomach- 
contents,  as  compared  with  gastric  analysis,  is  still  a  matter  of  dispute. 

Some  of  the  ardent  advocates  of  the  microscope  go  so  far  as  to  claim 
that  their  method  is  alone  necessary.  Undoubtedly,  in  many  cases  the 
clinical  symptoms,  gastric  analysis,  the  test  of  the  motor  function,  and 
macroscopic  inspection  of  the  contents  afford  sufficient  information  for 


Fig.  117. — Fasting  gastric  juice  containing  mucus,  snail  forms,  epithelial  cells,  and 

amorphous  material. 

diagnosis.  I  do  not  wish,  however,  to  depreciate  the  value  of  the  micro- 
scope, as  in  some  cases  it  is  of  fundamental  importance. 

Gastric  Secretion. — When  fasting,  the  gastric  secretion  sho\^s  normally 
under  the  microscope  epithelial  cells,  cell  nuclei,  some  mucus,  amorphous 
material,  and  microorganisms.  Jaworski'^  describes  spiral  or  snail-like 
bodies  in  cases  of  hyperchlorhydria,  but  Boas  believes  they  are  quite  com- 
mon and  that  they  are  developed  from  the  mucus  *by  the  action  of  the 
gastric  juice  (Fig.  117).  Einhorn  has  found  them  in  patients  with  normal 
secretion. 

Mucus. — Mucus  from  the  bronchi  and  lungs  is  characterized  by 
the  presence  of  alveolar  cells  and  myelin  drops;  while  the  occurrence 
of  a  great  many  columnar  epithelial  cells  is  evidence  of  its  origin  from  the 
gastric  mucous  membrane  while  squamous  epithelia  show  it  is  from  the 
pharynx  or  mouth. 

In  doubtful  cases  the  microscope  will  thus  determine  the  source  of  the 
'  Miinch.  med.  Wochenschr.,  1887,  No.  30. 


164 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


mucus,  either  by  examination  of  the  fasting  contents,  or  after  a  test-meal. 
The  clinical  symptoms  and  macroscopic  appearance  of  the  contents, 
as  described  under  Chronic  Gastritis,  will,  however,  generally  give 
sufficient  information. 

Paul  Cohnheim  holds  that  the  presence  of  free  nuclei  of  leukocytes 


Fig.   1 18. — a,  Nuclei  of  leukocytes;  b,  spiral  bocfies;  c,  nuclei  of  epithelial  cells;  d,  striated 

mucus. 


and  epithelial  cells  is  a  positive  evidence  of  hydrochloric  acid  and  pepsin 
(Fig.  118). 

I  believe  that  gastric  analysis  is  much  preferable  for  such  deter- 
mination. Importance  has  been  attached  to  the  presence  of  two  varieties 
of  infusoria,  the  Trichomonas  hominis  and  Megastoma  entericum,  notably 


Fig.  119. — a,  Pus  cells;  h,  trichomonas;  c,  megastoma;  d,  pavement  epithelium. 

by  Cohnheim  (Fig.  119).  He  believes  that  their  presence  is  pathognomonic 
of  carcinoma,  not  afecthig  the  motility  of  the  stomach.  Amebae  are  often 
associated  with  them. 

The  development  of  these  infusoria  requires  the  absence  of  hydro- 
chloric acid,  an  alkaline  medium,  and  the  existence  of  deep  folds  in  the 


EXAMINATION    OF   THE    FUNCTIONS    OF   THE    STOMACH 


165 


mucosa.  Previous  to  aspiration,  the  stomach-tube  and  receptacle 
should  be  warmed. 

To  differentiate  between  cancer  and  achylia  gastrica  in  the  suspected 
cases  with  emaciation,  gastric  distress,  and  achylia,  special  examination 
for  these  infusoria  is  advocated  by  Cohnheim.  The  presence  of  pus, 
especially  if  associated  with  blood  in  the  non-fetid  gastric  contents,  he 
also  believes  aids  in  the  early  diagnosis  before  the  tumor  is  palpable. 
Microscopic  pus  in  the  gastric  contents  shows  ulceration,  but  not  nec- 
essarily malignant  in  t5^e.  Phlegmonous  gastritis  and  the  ingestion  of 
pus  from  above  must  be  excluded. 

Sarcinae  and  the  Boas-Oppler  bacillus  can  be  examined  for,  both 
in  the  fasting  stomach  and  after  the  test-meal.  The  same  is  true  as 
regards  epithelial  cells  and  pieces  of  the  gastric  mucosa.  I  will  refer  to 
them  shortly. 

Gastric  Contents. — The  microscopic  examination  of  the  gastric 
contents  after  the  test-breakfast  or  dinner  shows,  under  normal  con- 


Fig.  120. — Benign  ectasia.  Yeast-cells  and  sarcinae  are  prominent:  o,  Muscle- 
fiber;  b,  plant-cells;  c,  sarcinae;  d,  starch  granules;  e,  degenerated  sarcinae;/,  yeast-cells; 
g,  fat  crystals. 

ditions,  a  few  starch  granules,  many  of  which  no  longer  appear  in  spiral 
form.  The  muscular  fibers  do  not  show  their  diagonal  stripes;  globules 
of  fat,  plant-cells,  and  microorganisms  are  present  in  small  numbers. 

Many  unchanged  starch  granules .  are  found  in  hyperchlorhydria 
and  hypersecretion,  and  the  muscle-fibers  are  well  digested;  while  with 
hypochlorhydria  (deficient  secretion)  unchanged  muscle-fibers  are 
present.  The  granules  of  starch  are  brought  out  clearly  by  the  addition 
of  I  drop  of  tincture  of  iodin,  giving  a  blue  reaction.  The  microscopic 
findings  are  here  confirmatory  of  macroscopic  inspection. 

The  varieties  of  microorganisms  have  been  thoroughly  studied  by 
DeBary,^  Nencki,^  Boas,^  and  others.  It  has  been  demonstrated  that 
they  may  be  present  even  in  hyperchlorhydria,  showing  that  the  hydro- 
chloric acid  does  not  always  prevent  fermentation, 

1  Archiv  f.  exper.  Path,  und  Therap.,  Bd.  20,  p.  243. 
*  Archiv  f.  exper.  Path.,  Bd.  28. 

2  Deutsch.  med.  Wochenschr.,  1892. 


i66 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


J.  Kaufmann^  has  described  a  case  of  hyperchlorhydria  in  which 
the  motor  function  of  the  stomach  was  not  markedly  disturbed,  but 
which  showed  fermentative  processes.  He  isolated  eight  varieties  of 
microorganisms  in  a  specimen  of  the  gastric  contents. 

Boas  has  also  described  the  development  of  sulphureted  hydrogen 
in  a  case  of  hyperchlorhydria.  In  general,  we  may  say  that  fermentation 
develops  in  cases  when  the  motility  of  the  stomach  is  reduced. 

Minkowski^  has  shown  that  if  free  hydrochloric  acid  be  abundant, 
yeast  and  thread  fungi  may  be  found;  while  if  it  is  absent,  numerous 
mold  organisms  are  present.  This  last  corresponds  to  the  findings  of  A. 
Rose  and  myself. 

Yeast. — A  few  isolated  yeast-cells  are  found  in  the  normal  stomach. 
In  ectasia  or  atony  of  marked  degree  the  yeast-cells  are  numerous,  arranged 
in  colonies,  and  are  in  active  process  of  germination  (Fig.  120). 

b 


Fig.  121. — a,  Boas-Oppler  bacilli;  h,  leptothrix;  c,  potato-cell;  d,  yeast-cells. 

Sarcinse. — These  occur  usually  in  cubes  or  bales,  and  are  only  patho- 
logic if  present  in  large  numbers,  as  in  benign  ectasia  or  atony  (Fig.  120) 
in  the  presence  of  hydrochloric  acid. 

They  are  rare  in  ectasia  from  cancer,  and,  if  present,  occur  usually 
in  cancer  developed  on  an  ulcer.  Their  presence  in  large  numbers 
is  an  aid  to  diagnosis. 

Boas-Oppler  Bacilli. — They  are  unusually  long,  non-motile  bacteria, 
and  are  characterized  by  their  large  size  and  end-to-end  arrangement 
(Fig.  121). 

They  must  be  differentiated  from  the  Leptothrix  buccalis  by  Gram's 
solution,  with  which  they  stain  brown,  the  leptothrix,  blue.  Kaufmann's^ 
investigations  prove  the  Boas-Oppler  bacillus  has  the  power  of  generating 
lactic  acid  from  different  sugars.  Stagnation  with  lactic  acid  fermentation 
is  not  specific  of  pyloric  carcinoma,  but  depends  on  the  absence  of  hydro- 
chloric acid  and  the  presence  of  stagnation.  These  conditions  exist  in 
stenotic  gastritis. 

1  Berlin,  klin.  Wochenschr.,  1895,  No.  6. 

2  See  Naunyn,  Mittheilungen  aus  der  medicin.  Klinik  zu  Konigsberg,  Leipsic,  1888. 
'  Weiner  klin.  Wochenschr.,  1895,  No.  S. 


EXAMINATION    OF    THE    FUNCTIONS    OF   THE    STOMACH  1 67 

These  bacilli  have  been  found  occasionally  in  stomach-contents 
that  contain  free  hydrochloric  acid  (Rosenheim).  Kaufmann  has  demon- 
strated them  in  19  out  of  20  cases  of  carcinoma. 

The  presence  of  these  bacilli,  with  pronounced  lactic  acid  fermenta- 
tion and  taken  in  connection  with  the  clinical  symptoms,  is  very  significant. 

Epithelial  Cells,  Particles  of  Tumor,  and  Fragments  of  Gastric  Mucosa. 
— Single  cells  cannot  be  diagnosed  as  cancer-cells,  but  cell-nests  must  be 
found.     These  are  rarely  discoverable. 

Occasionally,  after  aspiration  of  the  fasting  stomach  or  test-meal, 
or  after  lavage,  or  in  the  vomitus,  small  particles  of  tissue  may  be  found, 
which  on  staining  may  reveal  the  nature  of  a  tumor. 

Hemmeter  recommends  in  suspected  cases,  first,  thorough  lavage 
and  rectal  feeding  for  a  day;  then  passing  the  tube,  moving  it  about 
actively,  and  subsequent  aspiration  of  the  fasting  stomach.  This  is  to 
be  followed  by  lavage.     All  tissue  fargments  are  to  be  examined. 

Einhorn  finds,  especially  after  lavage,  or  at  times  after  aspiration, 
small  pieces  of  mucous  membrane  which  he  stains  and  examines.  Some 
point  to  erosions,  others  to  other  affections.  The  fragment  may  be 
normal  mucosa,  or  there  may  be  proliferation  of  the  connective  tissue, 
or  of  the  glands,  or  atrophy  (partial  or  complete),  or  vacuolization. 
These  conditions  are  illustrated  in  their  appropriate  chapters. 

A  positive  judgment  cannot  be  given  from  this  examination,  as  only 
a  small  area  may  be  actually  involved  and  no  changes  observed  in  the 
gastric  secretion.  On  the  other  hand,  a  bit  of  normal  mucosa  may  be 
aspirated  from  a  diseased  organ. 

Mold. — Mold  in  the  stomach  has  been  little  referred  to  in  literature 
as  a  pathologic  condition  except  by  Talma,  A.  Rose,  Naunyn,  Einhorn,^ 
and  Knapp.2  In  an  article  on  "Dilatation  of  the  Stomach"'  I  have 
already  referred  to  it. 

Einhorn  has  found  it  in  the  wash-water  of  the  empty  stomach  as 
blackish-gray  or  brownish-green  flakes  of  varying  number;  while  Knapp 
describes  it  as  coloring  the  chyme  a  yellowish  green  or  dark  red,  and  states 
that  it  has  been  mistaken  respectively  for  bile  or  blood  from  its  macro- 
scopic appearance.  He  emphasizes  the  necessity  for  appropriate  tests 
for  bile  and  blood,  and  not  the  diagnosis  from  appearances.  I  can  sub- 
stantiate this  in  one  case  at  least,  in  which  the  reddish-brown  material 
proved  to  be  mold. 

The  mold  flocculi  consist  of  clusters  of  spores  and  mycelia,  sometimes 
mixed  with  mucus  and  epithelial  cells.  Crystals  are  also  found,  which 
Knapp  considers  to  be  segments  of  mold  filaments. 

The  mold  generally  found  has  been  identified  by  E.  K.  Dunham  as  the 
Penicillium  glaucum,  though  Knapp  reports  in  addition  the  Oidium  albicans 
and  the  aspergillus  groups.  These  fungi  probably  adhere  quite  closely  to 
the  mucosa  and  may  involve  considerable  areas  (Fig.  122). 

Mold  fungi,  Streptothrix  Foersteri,*  a  rare  condition  have  been  re- 
covered from  the  gastric  contents  by  Stanley. 

'  Medical  Record,  June  6,  igcxj. 

*  Organacidia  Gastrica,  Sept.  6,  1902. 
^  Medical  News,  Aug.  16,  1904. 

*  Journal  A.  M.  A.,  July  11,  1914. 


i68 


DISEASES    or    THE    STOMACH    AND    INTESTINES 


Einhorn  reports  mold  formation  in  hyperchlorhydria,  in  some  cases 
attended  with  hypersecretion,  and  also  in  gastralgia  with  normal  or  re- 
duced gastric  secretion. 

Knapp  holds  that  the  presence  of  organic  acids  in  the  stomach  has  a 
decided  bearing,  and  that  succinic  acid  and  mold  go  hand  in  hand,  the 
presence  of  the  former  being  conclusive.  His  test  for  succinic  acid  is  as 
follows: 

Extract  i  c.c.  of  filtered  chyme  with  4  c.c.  of  ether,  and  float  this 
extract  on  a  solution  of  ferric  chlorid  (i  drop  of  a  10  per  cent,  ferric  chlorid 
to  2  c.c.  of  distilled  water)  in  a  narrow  test-tube.  At  the  line  of  junction 
is  a  dark  mahogany-red  ring.  He  further  describes  symptoms  in  many 
respects  resembling  severe  hyperchlorhydria,  with  spasm  of  the  pylorus, 
and  believes  the  condition  influenced  by  saccharine  material  in  the  chyme. 

In  the  experience  of  A.  Rose  and  the  author,  diminished  motility  of  the 
stomach  is  a  marked  factor  in  favoring  the  growth  of  mold.     I  have  found 


Fig.  122. — Green  mold  follicle,  mycelia,  spores,  and  crystals. 

it  Id  cases  of  atonic  ectasia,  producing  many  of  the  symptoms  of  chronic 
gastritis,  and  again  in  benign  stenosis  with  hypersecretion.  The  subject 
requires  still  further  investigation. 

Treatment  of  Mold. — Rose  finds  the  administration  of  i  minim  (0.059 
c.c.)  doses  of  beechwood  creosote  or  carbonate  of  creosote  5  grains  (0.3) 
t.  i.  d.  of  value,  and  lavage  is,  of  course,  indicated,  preferably  with  warm 
water — i  liter  followed  by  lavage  with  nitrate  of  silver  i :  2000,  or  spraying , 
the  stomach  with  the  latter,  as  suggested  by  Einhorn. 

The  general  treatment  should  be  according  to  the  other  conditions 
present. 


DETERMINATION  OF  THE  ABSORPTIVE  FUNCTION  OF  THE   STOMACH 

The  absorptive  function  of  the  stomach  is  usually  tested  by  the  method 
of  Penzoldt  and  Faber,  as  follows:  0.2  of  potassium  iodid  is  administered 
in  a  gelatin  capsule,  and  the  saliva  or  urine  examined  every  minute  or 
two  with  starch-paper  and  fuming  nitric  acid.     The  strip  of  paper  is 


EXAMINATION   OF   THE    FUNCTIONS    OF   THE    STOMACH  169 

moistened  with  saliva  or  urine  and  then  touched  with  a  drop  cf  the  acid. 
A  violet  or  blue  color  is  the  reaction.  It  takes  six  and  one-half  to  fifteen 
minutes  before  the  reaction  appears  in  normal  conditions.  In  pathologic 
cases  it  is  retarded. 

The  test  should  be  made  on  an  empty  stomach,  as  with  the  full  organ 
it  is  retarded.  It  is  self-evident  that  the  gastric  digestion  of  proteins — 
and  hence  their  absorption — is  delayed  in  cases  of  subacidity  or  anacidity, 
while  these  conditions  are  not  so  important  for  the  digestion  of  carbo- 
hydrates. 

In  some  cases  the  absorption  of  iodid  is  normal,  though  we  know  protein 
digestion  is  interfered  with,  so  that  I  do  not  consider  the  test  in  every  case 
reliable.  Hershell  gives  a  capsule  containing  2  decigrams  of  powdered 
rhubarb.  Under  normal  conditions  the  urine  gives  a  red  color  with  liquor 
potassse.     They  are,  however,  the  best  tests  so  far  known. 

Motor  Functions  of  the  Stomach. — By  this  we  mean  the  peristaltic 
action  of  tJte  stomach  which  expels  its  contents  into  the  intestine.  The 
impairment  of  the  motor  power  is  fully  as,  and  in  many  cases  more,  impor- 
tant than  damage  to  the  secretory  functions.  Under  normal  conditions 
after  the  Ewald  test  breakfast,  about  50-75  c.c.  of  gastric  are  aspirated. 
The  quantity  of  chyme  found  within  the  stomach  an  hour  after  the  break- 
fast is  an  index  of  the  motor  function  of  the  organ.  If  100  c.c.  or  more  is 
aspirated  at  this  time,  or  varying  quantities  in  2  hours,  motor  insufficiency 
is  considered  to  be  present;  the  greater  the  residue,  the  greater  the  motor 
insufficiency.  With  the  aspirating  bulb  employed  by  the  author,  particu- 
larly if  aspiration  be  performed  not  only  with  the  patient  sitting  up,  but 
also  lying  on  the  right  side,  so  that  all  the  gastric  contents  will  gravitate 
into  the  pars  pylorica,  quite  complete  emptying  of  the  stomach  can  be  secured. 
This  method  is  quite  practical  for  determination  of  the  motor  function 
and  is  sufficient  in  many  cases.  Lesser  degrees  of  motor  insufficiency  may 
be  found — 100  c.c.  of  contents  or  slightly  more  one  hour  after  the  test 
breakfast — which  may  account  for  some  of  the  symptoms,  and  yet  the 
radiograph  6  hours  after  barium  ingestion,  shows  the  stomach  to  be  empty. 
The  radiologist  may  therefore  state  the  motor  functions  are  normal  in 
such  a  case  and  be  in  error.  I  often  administer  a  test  supper  or  dinner  the 
night  before,  adding  to  it  spinach,  boiled  rice  and  six  raisins  without  seeds. 
When  motor  insufficiency  is  marked,  the  spinach  particularly  may  appear 
in  the  aspirated  contents  the  following  morning.  To  determine  that  the 
stomach  is  empty,  air  can  be  forced  into  the  organ  by  covering  the  free  end 
of  the  bulb  and  squeezing  the  latter.  If  no  bubbling  is  heard  the  stomach 
may  be  considered  empty.  There  should  be  no  contents  two  hours  after 
the  test  breakfast. 

An  excellent  method  of  testing  the  motor  power  is  by  the  test-meal. 
Leube's  is  the  oldest  method.  He  administered  a  plate  of  soup,  a  beef- 
steak, and  a  roll.  If  the  stomach  was  found  empty  seven  hours  later  and 
nothing  could  be  washed  out,  it  indicated  that  its  motor  power  is  suffi- 
ciently active.  If  the  food  remains  in  the  stomach  longer,  the  motor 
power  is  reduced.  The  greater  the  residue  (often  350-400  c.c),  the  greater 
the  motor  insufficiency. 

We  must  remember  that  in  pyloric  stenosis  the  motor  power  may  be 


170  DISEASES    OF   THE    STOMACH   AND   INTEISTINES 

really  increased  in  endeavoring  to  overcome  the  obstacle,  but  that  food 
remains  in  the  stomach  for  an  abnormal  length  of  time;  strictly  speaking, 
it  is  a  relative  motor  insufficiency.  If  five  hours  after  a  test-meal  a  small 
amount  of  chyme  is  aspirated,  the  motor  power  is  good.  If  large  quantities 
are  found  six  hours  after  the  meal,  the  motor  function  is  absolutely  (or  if 
stenosis,  relatively)  decreased.  Greater  degrees  of  insufficiency  may  be 
present.  For  example,  lavage  is  performed  and  a  test-supper  admin- 
istered, say,  at  12  p.  m.  and  the  contents  aspirated  seven  or  eight  hours 
later.  In  one  case  there  may  be  a  small  quantity  of  food  remaining,  and 
in  another  case  a  large  amount;  while  in  another,  none.  As  noted,  chopped 
spinach,  a  few  raisins,  or  a  piece  of  fig  are  a  good  addition  to  the  test,  as 
they  are  readily  recognized.  Boiled  rice  can  be  added.  The  presence  of 
food  ingested  at  a  previous  meal  shows  marked  motor  insufficiency. 

Boas  recommends  cold  meat  with  rolls  and  butter  and  a  large  cup  of 
tea. 

It  may  be  more  convenient  to  follow  the  same  procedure,  but  give  the 
meal  at  lunch-time.  I  sometimes,  as  a  variation,  administer  a  test-supper 
after  previous  lavage  and  aspirate  in  the  morning  to  test  the  motor  func- 
tion, following  immediately  with  the  test-breakfast  to  examine  the  secre- 
tory function,  and  for  lesser  degrees  of  motor  insufficiency. 

With  marked  dilatation  from  pyloric  stenosis,  it  is  at  times  difficult  to 
completely  empty  the  organ.     The  following  method  is  at  times  employed. 

Mathieu-R emend  Method. — Mathieu  and  Remond  suggest  the  follow- 
ing method  of  determining  the  total  quantity  for  motor  insufficiency. 

After  removal  of  the  contents  a  funnel  is  attached  to  the  tube  and 
200  c.c.  of  water  poured  into  the  stomach.  The  funnel  is  moved  up  and 
down  several  times,  and  the  patient  shakes  the  abdomen  so  that  complete 
mixture  of  the  water  and  contents  occurs.  They  are  then  removed  by  a 
combination  of  siphonage  and  expression. 

The  quantity  of  liquid  originally  contained  in  the  stomach  is  equal  to 
the  number  of  cubic  centimeters  of  water  poured  into  the  stomach  multi- 
plied by  the  degree  of  acidity  of  the  second  portion  removed,  divided  by 
the  figure  resulting  by  deducting  the  degree  of  acidity  of  the  second  por- 
tion from  that  of  the  first  plus  the  portion  previously  withdrawn. 

Salol  Test  {Ewald  and  Siever's  Method). — Salol  is  not  decomposed  in 
the  stomach,  but  in  the  alkaline  medium  of  the  intestine.  Here  it  is  split 
up,  and  the  salicylic  acid  is  absorbed  and  eliminated  in  the  urine  as  sali- 
cyluric acid.  The  latter  is  recognized  by  testing  the  urine  with  neutral 
ferric  chlorid  solution,  which  gives  a  violet  color  with  this  acid. 

The  patient  takes  salol  15  grains  (i.o)  in  two  gelatin  capsules  half  an 
hour  after  a  light  meal.  The  bladder  is  first  emptied.  Thereafter  he 
urinates  every  half-hour  for  about  two  hours,  and  the  different  specimens 
of  urine  are  tested  with  the  iron  solution.  Under  normal  conditions  the 
reaction  appears  in  from  thirty  to  seventy-five  minutes.  With  retarded 
motility  it  takes  two  hours  or  more. 

Ewald  treats  the  urine  with  ether  and  examines  the  ethereal  residue; 
while  Einhorn  moistens  a  piece  of  filter-paper  with  the  urine  and  touches 
the  middle  of  it  with  the  iron  solution. 

Huber  suggests  to  determine  the  time  required  for  the  complete  dis- 


EXAMINATION    OF    THE    FUNCTIONS    OF   THE    STOMACH  I7I 

appearance  of  the  reaction  in  the  urine.  The  longer  the  time  required 
for  the  salol  to  be  absorbed  and  entirely  eliminated  through  the  urine,  the 
longer  it  has  remained  within  the  stomach.  He  found  that  normally  the 
excretion  of  the  salicyluric  acid  after  salol  was  administered  lasted  twenty- 
four  hours;  in  patients  with  diminished  motor  function  it  lasted  forty-eight 
hours  or  more. 

lodipin  Test. — lodipin  is  decomposed  in  the  intestine.  Heichelheim 
gives  1.6  gm.  iodipin  in  gelatin  capsules  at  breakfast.  The  saliva  is  then 
examined  every  fifteen  minutes  for  iodin  by  starch-paper  and  fuming 
nitric  acid.     In  normal  cases  the  reaction  appears  within  an  hour. 

Klemperer's  Oil  Test. — Oil  is  not  absorbed  in  the  stomach.  After 
washing  the  stomach,  loo  c.c.  of  pure  olive  oil  are  poured  into  the  empty 
organ.  Two  hours  later  the  stomach  is  thoroughly  aspirated.  The 
difference  between  the  original  quantity  of  oil  and  that  withdrawn  indicates 
the  condition  of  the  motor  function.  Normally  at  this  time  only  20  to  40 
c.c.  of  oil  should  be  aspirated. 

Emhorn's  Gastrograph. — Einhorn  has  invented  a  deglutible  ball, 
arranged  with  an  electric  circuit,  so  that  the  movements  which  mix  and 
break  up  the  food  can  be  registered. 

Hemmeter-Moritz    Method. — This    method    has    been    independently, 
employed  by  Hemmeter  and  Moritz. 

A  thin,  deglutible  bag  is  attached  to  an  esophageal  tube.  The  bag 
is  then  blown  up  and  connected  with  a  tambour  on  the  Ludwig  kymograph, 
which  registers  all  the  movements  with  a  pen.  A  pneumograph  is  tied 
about  the  chest  to  record  the  respiratory  movements  as  a  basis  of  com- 
parison. The  muscular  contractions  of  the  stomach  are  demonstrated 
on  the  record  as  independent  of  the  respiration. 

These  instruments  are  of  interest  scientifically,  but  their  practical 
value  has  not  been  demonstrated. 


CHAPTER  VII 
DIET 

The  study  of  nutrition,  both  in  health  and  disease,  is  important,  but 
it  will  only  be  possible  to  enunciate  the  general  principles. 

There  are  three  groups  of  food  stuffs — Proteins,  carbohydrates,  and 
fats — procured  from  the  animal  and  vegetable  kingdoms,  which  in  com- 
bination furnish  the  most  suitable  form  of  nourishment.  Climatic 
conditions  and  environment  have  an  influence  on  the  requirements  for 
nutrition.  In  extremely  cold  climates  the  Eskimos  have  lived  for  many 
generations  on  nearly  an  exclusively  nitrogenous  diet,  with  the  addition 
of  a  large  amount  of  fat,  which  produces  the  greatest  number  of  heat 
units.  In  hot  regions  many  of  the  races  live  principally  on  a  non- 
nitrogenous  diet.  We  also  know  that  vegetarians  live  and  thrive  on 
carbohydrates. 

A  mixed  diet  is  the  most  suitable  form  of  nourishment. 

DIET  IN  HEALTH 

Voit  has  emphasized  the  fact  that  the  smallest  amount  of  protein, 
with  non-nitrogenous  food  added,  that  will  keep  the  body  in  continual 
vigor  is  the  ideal  diet.  He  holds  that  a  healthy  adult  of  average  weight 
should  ingest  loo  gm.  of  albumin,  50  gm.  of  fat,  and  450  gm.  of  carbo- 
hydrate in  twenty-four  hours;  others  place  the  requirement  for  protein 
as  considerably  higher.  A  small  proportion  of  the  food  serves  the  purpose 
of  reconstructing  the  tissue  waste,  while  the  major  part  is  used  for  generat- 
ing the  heat  required  for  the  maintenance  of  life.  It  is,  therefore,  custom- 
ary to  speak  of  the  necessary  amount  of  heat  units  during  the  twenty- 
four  hours  instead  of  the  quantity  of  food. 

A  calorie  (or  heat  unit)  may  be  defined  as  the  amount  of  heat  re- 
quired to  raise  i  gram  of  water  i°C.  This  is  a  small  calorie.  A  large 
calorie  is  the  amount  necessary  to  raise  i  kilogram  of  water  i°C.  Hence 
a  large  calorie  equals  1000  small  calories. 

I  gm.  carbohydrate  yields  4.1  large  calories. 

I  gm.  fat  "     9.3      " 

I  gm.  protein  "     4.1      "         " 

In  order  to  calculate  the  calorie  value  of  any  kind  of  food,  the  number 
of  grams  of  albumin  that  are  contained  in  it  are  multiplied  by  4.1;  the 
grams  of  carbohydrate  by  4.1;  the  grams  of  fat  by  9.3.  These  are  added 
together  and  give  the  total  calorie  value  of  the  food.     For  example: 

172 


DIET  173 

100  gm.  albumin  X  4.1  =    410  calories. 

SO    "    fat  X  9.3  =    465      " 

450    "    carbohydrate  X  4.1  =  1845      " 

2720  total  calories. 

The  calorie  value  of  vegetable  protein  is  slightly  less  than  that  of 
animal  protein;  50  gm.  of  fat  about  equal  113  gm.  of  starch  in  calorie 
value. 

Riegel  holds  that  a  human  being  at  rest,  demands  about  35  calories 
per  kilogram  of  his  body  weight,  and  a  person  performing  light  work  about 
40  calories  per  kilo.  From  this  estimate,  the  calorie  value  of  the  food  of 
an  individual  weighing  50  kilos  is  from  1750  to  2000  calories.  The  weight 
of  the  patient  must,  therefore,  be  known  in  order  to  select  the  correct 
amount  of  nourishment. 

Rubner  states  that  different  articles  of  food  can  replace  each  other 
according  to  their  calorie  value,  and  that  it  is  immaterial  in  what  form 
the  calories  are  introduced  into  the  organism.  This  may  be  taken  advan- 
tage of  temporarily  in  certain  pathologic  conditions  when  it  is  necessary 
to  limit  some  special  variety  of  food,  such  as  the  carbohydrates.  On  the 
other  hand,  a  certain  amount  of  protein  is  necessary  for  the  organism, 
while  unquestionable  damage  can  be  done  by  excess  in  this  direction. 

The  amount  of  heat  produced  during  digestion  and  assimilation  depends 
upon  the  digestibility  of  food,  that  is  upon  the  amo.unt  of  energy  needed 
to  bring  about  its  digestion.  Easily  digested  foods  causes  little  expendi- 
ture of  energy  for  digestion,  'while  food  difficult  of  digestion  calls  for  more 
energy.  Chapin^  illustrates  that  physiological  food  value  and  calorie  value 
are  not  identical.  For  example,  two  foods  when  burned  in  calorimeter 
may  yield  1000  calories  each,  yet  the  digestion  of  one  food  may  call  for 
the  expenditure  of  100  calories,  while  700  calories  of  energy  are  used  in 
the  digestion  of  the  other  food,  hence  they  would  have  a  net  value  respect- 
ively of  900  and  300  calories.  Some  foods  have  no  nutritive  value, 
because  the  energy  required  for  their  digestion  is  greater  than  the  energy 
they  contain.  The  carbohydrates  and  fats  are  primarily  suppliers  of 
energy  and  secondarily  of  heat.  Babcock  has  recently  shown  that  they  also 
supply  water  to  the  cells  in  a  manner  that  controls  cell  nutrition  and 
growth,  so-called  metabolic  water.  Its  function  is  to  cause  growth  and  a 
flow  of  nutriment  from  the  blood  to  the  cells.  The  fats  are  of  particular 
value  in  this  regard — especially  milk  fat  and  egg  yolk.  Overemphasis 
should  not,  therefore,  be  placed  on  the  calorie  value  of  foods,  but  their  < 
digestibility,  suitability  to  the  individual  case  and  their  capacity  to  produce 
improvement  or  in  the  case  of  an  infant,  proper  development  and  growth, 
must  be  considered. 

The  results  of  scientific  study  are  opposed  to  the  prevailing  dietary 
standards,  especially  in  regard  to  protein  foods.  It  is  true  that  no  other 
form  of  food  can  take  the  place  of  proteins,  for  a  certain  quantity  is  needed 
each  day  to  replace  the  loss  of  tissue  material  broken  down,  and  our  choice 
of  the  varied  articles  of  diet  should  be  regulated  by  the  amount  of  pro- 

^  The  Double  Function  of  Fats  and  Carbohydrates  in  Nutrition,  N.  Y.  Med.  Jour., 
Feb.  8,  1913. 


174  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

tein  they  contain.     It  is  not  necessary,  however,  that  they  should  exceed 
the  other  foods  in  amount,  or  approach  them  in  quantity. 

Russel  H.  Chittenden^  has  clearly  demonstrated  by  his  scientific 
researches  that  the  recommended  dietary  standards  are  excessive  in 
quantity,^  especially  in  regard  to  proteins.  They  do  not  undergo  com- 
plete oxidation  in  the  body  like  non-nitrogenous  foods,  but  there  is  left 
behind  a  residue  of  non-combustible  matter,  crystalline  nitrogenous  pro- 
ducts, which  ultimately,  if  occurring  in  excess  of  the  requirements  of  the 
body,  prove  injurious  to  the  gastro-intestinal  tract,  liver,  kidneys,  and  the 
circulatory  and  nervous  system. 

The  fats  and  carbohydrates  are  easily  eliminated,  becoming  carbonic 
acid  gas  and  water.  Potential  energy,  however,  can  be  fully  as  advanta- 
geously met  by  the  non-nitrogenous  foods,  carbohydrates,  and  fats.  On 
the  other  hand  overfeeding  with  a  tendency  to  obesity,  is  an  evil,  as  the  fat 
acts  as  a  mechanic  obstacle  to  the  activity  of  the  body  and  interferes 
with  the  movements  of  the  heart  and  other  organs;  and,  in  addition, 
fatty  degeneration  may  occur. 

It  is  interesting  to  note  that  the  body  cells  require  a  certain  amount  of 
mineral  ash  in  the  food,  in  order  to  perform  their  functions.  A  dog,  for 
example,  fed  abundantly  on  all  varieties  of  food  from  which  the  ash  had 
been  extracted  died  in  thirty  days. 

Though  the  author  has  been  criticized  for  his  approval  of  Chittenden's 
low  protein  diet  in  health,  he  must  confess  that,  from  personal  experience 
and  prolonged  investigation,  he  must  contiijue  to  advocate  Chittenden's 
methods.  Unquestionably  a  considerable  percentage  of  temporary  dis- 
turbances, or  permanent  damage  to  the  gastro-intestinal  tract,  the  liver, 
kidneys,  and  in  the  arterial  and  nervous  systems  can  be  imputed  to  exces- 
sive protein  diet,  from  the  intestinal  putrefaction  resulting  therefrom. 
Rheumatic  affections,  gravel,  and  rheumatoid  arthritis,  the  writer  believes, 
are  influenced  by  the  same  factor. 

Mastication,  Fletcherism. — Unquestionably  thorough  mastication  and 
insalivation  of  our  food  which  necessitate  slow  eating,  are  of  value.  Fletcher 
claims  that  by  his  method,  there  is  an  early  occurrence  of  satiety  on  the 
ingestion  of  small  amounts  of  food,  and  hence  excess  is  avoided.  He 
cites  722  chews  to  masticate  ^i  ounce  of  onion  in  one  case.  This  would 
destroy  the  appetite  both  of  operator  and  spectator.  Most  reformers 
are  extremists,  but  the  writer  must  credit  Fletcher  with  having  done 
some  good. 

It  is  clear  that  a  man  of  170  pounds  weight  has  more  protein  tissue  to 
nourish  than  one  of  130  pounds,  and  consequently  what  will  suffice  for  the 
latter  will  not  for  the  former.  Dietary  standards  are  merely  approximate 
and  depend  on  the  physical  work  to  be  performed,  the  body  weight,  sex, 
age,  climate,  etc.  There  is  doubtless  a  specific  coefficient  of  nutrition 
characteristic  of  the  individual. 

Chittenden  demonstrated  on  professional  men,  soldiers,  and  athletes 
that  they  could  perform  their  duties  with  greater  vigor,  and  their  strength 
as  measured  by  tests  was  increased  under  diminished  protein  diet;  in 

^  Nutrition  of  Man. 

2  Physiologic  Economy  in  Nutrition. 


DIET  175 

fact,  with  about  one-half  the  amount  as  compared  with  the  standards 
suggested. 

Chittenden's  Table 

Fuel  value. • 
60  gm.  of  protein  are  contained  in —  Calories 

H  lb.  fresh  lean  beef  (loin) 308 

9  hens'  eggs 720 

^i  lb.  sweetbread 660 

H  lb.  fresh  liver 432 

Ji  lb.  lean  smoked  bacon 1820 

H  lb.  halibut  steak 423 

H  lb.  salt  codfish  (boneless) 245 

2H  lbs.  oysters,  solid 506 

I'i  lb.  American  pale  cheese 1027 

4  lbs.  (2  quarts)  of  whole  milk 1300 

56  lb.  uncooked  oatmeal 155° 

iW  lbs.  shredded  wheat 2125 

I  lb.  uncooked  macaroni 1665 

I H  lbs.  white  wheat  bread 1 5  20 

iV*  lbs.  crackers 2381 

iH  lbs.  flaked  rice 2807 

H  lb.  dried  beans 963 

iji  lbs.  baked  beans 1125 

H  lb.  dried  peas 827 

1IM2  lbs.  potato-chips 5728 

%  lb.  almonds 2020 

%  lb.  pine-nuts,  pignolias 1 1 38 

1%  lbs.  peanuts 3584 

10  lbs.  bananas  (edible  portion) 4600 

10  lbs.  grapes 4500 

II  lbs.  lettuce 990 

15  lbs.  prunes 5550 

33  lbs.  apples 9570 

The  standards  of  100  gm.  of  protein  or  more  mean  the  excretion  of 
excessive  nitrogen  through  the  urine.  Chittenden^  found  by  experiment 
that  the  average  need  of  protein  food  by  adults  is  fully  met  by  a  daily 
metabolism  equal  to  an  exchange  of  0.12  gm.  of  nitrogen  per  kilogram  of 
body  weight.  This  means  a  catabolism  of  ^  gm.  of  protein  matter  daily 
per  kilogram.  The  intake  of  protein  food  must  be  somewhat  in  excess  of 
protein  catabolism,  since  not  all  of  the  protein  is  available,  and  this  is  a 
variable  amount,  depending  on  the  proportion  of  animal  and  vegetable 
foods  with  their  different  degrees  of  digestibility  and  availability.  The 
required  intake  of  protein  Chittenden  places  at  0.85  gm.  per  kilogram  of 
body  weight,  giving  a  maximum  for  safety.  Hence,  for  a  man  weighing  70 
kilos  (154  lbs.)  there  would  be  required  daily  59.5  gm.  (say,  60  gm.)  of 
protein  food  to  meet  the  needs  of  the  body.  This  is  about  one-half  the 
Voit  standard,  and  far  below  that  of  many  other  so-called  diets.  As  the 
specialist  is  so  often  consulted  as  to  the  proper  diet  to  maintain  the  health 
of  the  body,  I  quote  Chittenden  at  some  length,  being  a  firm  believer  in 
his  principles. 

The  daily  protein  requirement  of  60  gm.  can  be  obtained  from  >^ 
pound  of  uncooked  lean  meat,  of  which  loin  steak  is  the  type.    Lamb, 

^Fuel  value  of  the  quantity  needed  to  furnish  60  gra.  of  protein. 
^Physiologic  Economy  in  Nutrition;  Nutrition  of  Man. 


176  DISEASES    or    THE    STOMACH    AND    INTESTINES 

veal,  poultry,  or  lean  flesh  of  any  variety,  of  equivalent  weight,  will 
approximately  furnish  the  same  amount  of  protein. 

Fish,  such  as  halibut  steak,  and  liver  require  ^  pound,  and  of  sweet- 
breads ^  pound  is  necessary. 

Of  salt  codfish  >^  pound  is  equivalent  to  the  same  weight  of  fresh 
beef,  while  of  lean  smoked  bacon  %  pound  is  necessary. 

Three  hen's  eggs  furnish  one-third  the  amount  of  protein  required  in 
twenty-four  hours.  Dried  peas  and  beans,  almonds,  and  pine-nuts  are 
as  rich  in  proteins  as  the  above-mentioned  animal  foods,  and  essentially 
the  same  weight  is  called  for  to  provide  the  daily  requirement  of  protein. 
The  same  is  true  of  cheese,  the  composition  of  K  pound  being  equivalent 
to  the  same  amount  of  protein,  but  of  much  higher  caloric  value  than  the 
equivalent  weight  of  fresh  beef. 

There  are  some  differences  in  digestibility  which  tend  to  lower  slightly 
the  availability  of  the  vegetable  products,  also  of  the  cheese,  which  neces- 
sitates a  slight  increase  in  the  amount  of  these  foods  to  equal  the  protein 
value  of  the  equivalent  weight  of  lean  beef. 

Certain  foods  are  poor  in  proteins,  such  as  fruits,  bananas,  grapes, 
prunes,  apples,  etc.,  lettuce,  and,  to  a  less  degree,  potatoes.  These  are 
all  palatable,  but  add  little  to  the  proteins,  even  when  given  in  large 
amount. 

The  radical  difference  between  the  animal  foods  and  those  of  veg- 
etable origin,  is,  that  the  fuel  value  necessary  to  furnish  the  60  gm.  of 
protein  is  small  in  the  former,  as  compared  with  that  of  the  vegetables;  ^2 
pound  of  lean  beef,  with  its  60  gm.  of  protein,  has,  for  example,  a  fuel  value 
of  only  308  calories,  while  ^  pound  of  almonds  has  one  of  2020  calories; 
^i  pound  of  cheese  has  one  of  1027  calories;  H  pound  of  dried  peas,  827 
calories.  This  is  due  to  the  proportion  of  fat  or  oil  present.  With  fat 
meat,  such  as  bacon,  the  calorie  value  rises  in  proportion  to  the  increase  of 
fat,  the  protein  decreasing  to  a  greater  or  less  degree. 

A  high  protein  (animal)  diet, cannot  serve  for  man.  In  a  male,  for 
example,  with  a  weight  of  70  kilos,  and  requiring  2800  calories,  it  would 
necessitate  the  ingestion  of  4>^  pounds  of  beef  to  secure  this  result,  or  nine 
times  more  protein  than  is  necessary  for  the  system. 

Certain  vegetable  foods  on  the  diet-list,  such  as  flaked  rice,  crackers, 
and  shredded  wheat,  contain  proteins,  with  carbohydrates  and  fat  in  such 
proportion  that  the  energy  requirement  would  be  met  with  essentially  by 
the  same  quantity  as  served  to  furnish  the  necessary  protein.  In  potatoes 
and  bananas  the  fuel  value  predominates  over  the  protein.  The  ideal 
diet  is  an  admixture,  such  as  wheat  bread  with  butter,  or  fat  bacon  to  add  to 
its  calorie  value,  shredded  wheat  with  cream,  crackers  with  cheese,  bread 
and  milk,  eggs  with  bacon,  meat  with  potatoes,  etc. 

Two  quarts  of  milk  will  furnish  half  the  requirement  of  an  average 
man,  and  reinforced  by  a  i-pound  loaf  of  wheat  bread,  gives  the  requisite 
amount.  A  better  combination  is  }i  pound  of  lean  beef,  %  pound  of 
bread,  and  K  pound  of  butter. 

According  to  Chittenden,  for  a  man  of  average  weight  of  70  kilos  (154 
pounds),  to  provide  the  requisite  quantity  of  food — i.e.,  60  gm.  of  protein 
and  2800  calories — the  following  is  a  sample  dietary: 


DIET 


177 


Breakfast:  Protein,  grams 

I  shredded  wheat  biscuit  (30  gm.) i'^^S 

I  teacup  of  cream  (120  gm.) 3.12 

1  German  water  roll  (57  gm.) 5 .07 

2  i-inch  cubes  of  butter  (38  gm.) 0.38 

Vi  cup  of  coffee  (100  gm.) o.  26 

with 

y*  teacup  of  cream  (30  gm,) o. 78 

I  lump  of  sugar  (10  gm.) 

12.  76 

Lunch:                                                                                             Protein,  grams 
I  teacup  home-made  chicken  soup  (144  gm.) S  ■  25 

1  Parker  House  roll  (38  gm.) 3  •  38 

2  i-inch  cubes  of  butter  (38  gm.) 0.38 

I  slice  lean  bacon  (10  gm.) 2 .  14 

I  small  baked  potato  (2  ounces — 60  gm.) i .  53 

1  rice  croquette  (90  gm.) 3 .  42 

2  ounces  maple  syrup  (60  gm.) 

I  cup  tea  with  i  slice  lemon 

I  lump  sugar  (10  gm.) 

16. 10 

Dinner:  Protein,  grams 

I  teacup  cream  of  corn  soup  (130  gm.) 325 

I  Parker  House  roll  (38  gm.) 3  •  38 

I  I-inch  cube  of  butter  (19  gm.) o.  19 

I  small  lamb  chop  broiled,  lean  meat  (30  gm.) 8.51 

I  teacup  of  mashed  potato  (167  gm.) 3-34 

Apple-celery  lettuce  salad  with  mayonnaise  dressing 

(50  gm.) 0.62 

I  Boston  cracker  split,  2  in.  in  diameter  (12  gm.). .  .      1.32 

>i-inch  cube  American  cheese  (12  gm.) 3.35 

Vi  teacup  of  bread  pudding  (85  gm.) 5 .  25 

I  demi-tasse  coffee 

I  lump  sugar  (10  gm.) 


29. 21 


Calories 
106 
206 

165 
284 


SI 
38 

850 

Calories 
60 
no 

284 

65 

55 
ISO 
166 

38 

928 

Calories 

72 

no 

142 

92 

175 


47 

SO 

150 

38 

951 


The  total  with  the  dietary  for  the  day  amount  to  58.07  gm.  of  protein 
and  2729  calories. 

The  figures  are  to  be  considered  only  approximately  correct. 

If  a  little  more  protein  is  required  without  changing  materially  the 
fuel  value,  a  boiled  egg  can  be  added  to  the  breakfast.  An  average  egg 
of  53  gm.  contains  6.9  gm.  of  protein  and  increases  the  fuel  value  by  80 
calories.  If  more  vegetable  protein  is  desired,  a  soup  of  split-peas  can  be 
introduced  without  changing  to  any  great  degree  the  calories;  thus,  one 
teacup  of  split-pea  soup  (1.44  gm.)  contains  8.64  gm.  of  protein,  while 
the  fuel  value  is  only  94  calories. 

The  addition  of  i  banana  (160  gm.)  will  increase  fuel  value  153  calories, 
but  will  only  add  2.28  gm.  of  protein. 

If  the  fuel  value  is  to  be  increased  without  change  in  the  protein 
contents  of  the  food,  recourse  can  be  had  to  butter,  fat  of  meat,  additional 
oil  in  salads,  or  to  syrup  and  sugar. 


178 


DISEASES    OF    THE    STOMACH   AND    INTESTINES 


Wheat  products  abounding  in  starch  still  show  a  large  proportion  of 
protein;  thus,  shredded  wheat  biscuit  (i  ounce),  which  is  a  type  of  many 
wheat  preparations  from  bread  and  biscuit  to  various  breakfast  foods, 
yield  about  3  gm.  of  protein  per  ounce  and  100  calories;  i  ounce  of  olive  oil 
contains  100  calories.  Whole  wheat  contains  phytin  which  is  laxative,  and 
bread  and  biscuit  made  therefrom  are  valuable  in  constipation.  Bran 
made  into  buns,  etc.,  contains  whole  wheat.  It  is  now  believed  that  the 
activation  of  the  bowels  from  bran  biscuit  is  to  a  large  extent  due  to  its 
whole  wheat  (phytin),  ingredient  and  not  merely  to  the  rough  particles. 
Potato,  chiefly  a  carbohydrate,  yields  nitrogen  the  equivalent  of  about 
%  gm.  of  protein  per  ounce.  If  a  large  volume  is  desired  without  much 
increase  in  real  food  value,  there  are  green  foods,  such  as  lettuce,  celery, 
greens  of  various  sorts,  fruits,  such  as  apples,  grapes,  oranges,  etc. 

Meat  augments  largely  the  intake  of  protein  and  adds  relatively  a 
small  amount  to  the  fuel  value. 

In  edible  nuts  the  content  of  protein  is  high,  in  some  cases  higher  than 
in  fresh  beef;  while  carbohydrates  and  fat  are  large  in  amount,  as  in 
almonds  and  peanuts. 

In  pine-nuts  and  Brazil  nuts  carbohydrates  are  small  in  quantity  as 
compared  with  peanuts,  almonds,  and  walnuts,  an  important  fact  where 
a  vegetable  rich  in  protein  is  desired,  but  with  freedom  from  starch  (see 
table). 


Proteid 
present 

Carbo- 
hydrate 
present 

Fat 
present 

Water 
present 

Mineral 
present 

Fuel 
value 
per  lb. 

Almonds  (edible  portion) 

Peanuts  (edible  portion) 

21.0 
25.8 

33-9 
17.0 
16.6 

17-3 
24.4 

6.9 

7.0 

16. 1 

54-9 
38.6 

49-4 
66.8 

634 

4.8 
9-2 
6.4 

5-3 

2-5 

2.0 
2.0 
3-4 
3-9 

I -4 

3030 
2560 

2845 
3265 
3285 

Pine-nuts  (edible  portion) 

Brazil  nuts  (edible  portion) 

Soft-shell  walnuts 

United  States  Department  Agriculture  Bulletin  No.  28. 

Green  vegetables,  such  as  spinach,  help  the  bowel  action. 

Natural  sugars  are  of  value,  especially  such  as  occur  in  oranges,  grapes, 
prunes,  dates,  plums,  and  bananas,  and  to  a  less  degree  in  apricots,  peaches, 
pears,  apples,  figs,  strawberries,  raspberries,  and  blueberries. 

Chittenden^  has  given  considerable  study  as  to  the  value  of  the  pine- 
apple. He  has  demonstrated  that  the  juice,  in  fresh  condition,  contains 
an  enzyme  or  enzymes  of  a  proteolytic  nature,  active  in  either  an  alkaline 
carbonate  or  in  an  acid  medium.  It  was  found  to  be  most  active  at  122° 
to  i40°F.,  and  i58°F.  destroys  it,  but  it  possesses  digestive  power  at 
86°F.  Leucin,  tyrosin,  proteoses,  and  peptones  were  formed,  so  that  its 
enzyme  is  more  closely  related  to  trypsin  than  to  pepsin.  It  is  capable  of 
digesting  a  large  amount  of  protein  with  great  rapidity,  and  hence  may  be 
valuable  in  conditions  with  deficient  hydrochloric  secretion. 

Apples,  when  ripe  and  well  masticated,  are  good,  and  a  baked  apple 
is  wholesome.    . 

^  Journal  of  Physiology,  xv,  p.  249. 


DIET  1 79 

There  is  occasionally  an  idiosyncrasy  to  strawberries,  and  some  suffer 
from  fermentation  from  various  fruits. 

Soy  Gruel  Flour. — The  Soy  bean,  which  is  largely  employed  by  the 
Chinese  and  Japanese  as  an  article  of  food,  contains  about  25  per  cent,  of 
protein.  Among  products  made  from  these  beans  are  natto,  miso  (a 
fermented  product),  tofu,  precipitated  plant  casein  of  the  bean  compressed 
into  a  tablet,  and  shogu  or  soy  sauce.  J.  Ruhrah^  has  recently  secured 
the  manufacture  of  a  flour  made  from  this  bean,  which  he  advocates  as  a 
useful  addition  to  the  diet  of  infants  when  it  is  desired  to  supply  an  early 
digestible  protein  free  from  starch.  Sinclair^  has  reported  excellent  results 
in  infant  feeding.  Friedenwald  has  also  recommended  it  as  a  source  of 
protein  for  diabetics  who  tire  of  meats,  and  it  has  proved  useful  in  the 
form  of  a  weak  gruel  in  diarrheas  and  intestinal  disturbances,  and  when 
meat  is  contraindicated.  On  account  of  the  removal  of  the  coarse  fibrous 
hulls,  the  per  cent,  of  protein  in  the  flour  is  nearly  one-third  greater  than 
in  the  whole  bean.     The  analysis  of  the  soy  gruel  flour  is  as  follows: 

Per  cent. 

Protein  (N.  X  6.25) 44.64 

Fat 00 .  43 

Mineral  matter 4 .  20 

Moisture 526 

Crude  fiber 2.35 

Cane-sugar 9-34 

Non-nitrogenous  extract 14-78 

Starch None 

Reducing  sugars None 

Polarization  normal  weight  due  to  optically  active  substance 
other  than  cane-sugar  (included  in  proteins  and  non-nitrogen- 
ous extract) 7 .  68° 

Each  ounce  of  the  flour  yields  about  13  gm.  of  protein  and  120  calories 
and  it  can  be  used  as  a  gruel,  in  broths,  and  in  making  biscuits  or  muffins. 
It  may  be  mixed  with  cereals,  barley  jelly,  cream  of  wheat,  etc.  The 
following  table  shows  the  composition  and  calorie  value  of  the  gruels 
made  from  this  flour: 

Amount  Protein  Fat.  Sugar  Calories 

per  cent,  per  cent,  per  cent. 

J'i  oz.  ( I  level  tablespoonful  to  quart) ..  .  0.35  0.15  0.08         30 

}4  oz.  (2  level  tablespoonfuls  to  quart).  .  .  0.70  0.30  0.15         60 

%  oz.  (3  level  tablespoonfuls  to  quart) ...  i . 00  o.  45  0.23         90 

1  oz.  (4  level  tablespoonfuls  to  quart)  ...  i .  40  o .  60  o.  30  120 

2  oz.  to  quart 2 . 80  i .  20  o.  60  240 

3  oz.  to  quart 4 .  20  i .  80  o .  90  360 

4  oz.  to  quart 5 .  60,  2 .  40  i .  20  480 

5  oz.  to  quart 7 .  00  3 .  00  i .  50  600 

6  oz.  to  quart 8.40  3.60  1.80  720 

7  oz.  to  quart 9 .  80  4 .  20  2.10  840 

8  oz.  to  quart 1 1 .  00  4 .  80  2 .  40  960 

The  calorie  value  of  the  gruel  can  be  increased  by  adding  condensed 
milk,  sugar,  or  cereals. 

^'Archiv.  Pediat.,  July,  1909;  Jour.  Amer.  Med.  Assoc,  July  10,  1909,  and  May 
21,  1910;  Soy  Bean  Cookery,  Med.  Rec,  Sept.  23,  1911;  Amer.  Jour.  Med.  Sci.,  Dec, 
1910. 

*N.  Y.  State  Journal  of  Medicine,  Feb.,  1916  (Sinclair). 


l8o  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

(i  oz.)  4  level  tablespoonfuls  of  barley  or  wheat  flour  will  add  loo  calories. 

(i  oz.)  4  level  tablespoonfuls  of  oat  flour  will  add  115  calories. 

(i  oz.)  2  level  tablespoonfuls  of  granulated  sugar  will  add  100  calories. 

(i  oz.)  3  level  tablespoonfuls  of  milk-sugar  will  add  100  calories. 

Two  ounces  of  sugar  in  a  32-oz.  mixture  =  6  per  cent. 

The  following  cooking  directions  are  advised  by  Ruhrah: 

Gruels. — A  quart  of  gruel  is  made  by  boiling  from  i  level  tablespoonfui  to  6  ounces 
of  the  soy  gruel  flour  in  i  quart  of  water  for  fifteen  minutes,  adding  water  to  make  up 
for  loss  by  evaporation.     Salt  should  be  added  to  taste. 

Composition  ^f^h   r^J^l'^-  "^dStSf 

per  cent,  per  cent,  p^^  ^^^^ 

One  level  tablespoonfui  to  quart o-35       015       0.08 

One  ounce  (4  tablespoonfuls  to  quart) i .  40       o .  60       0.30 

These  gruels  do  not  thicken  during  cooking,  as  they  contain  no  starch,  and  readily 
settle  on  standing.  This  may  be  overcome  by  adding  i  to  2  heaping  teaspoonfuls  of 
barley,  oat,  or  wheat  gruel  flour  before  cooking,  which  will  add  from  0.6  to  1.2  per 
cent,  starch  to  the  gruels,  and  also  slightly  increase  the  percentage  of  protein. 

Broths. — Add  from  i  to  8  ounces  of  the  flour  to  i  quart  of  beef,  mutton,  veal,  or 
chicken  broth  and  boil  for  fifteen  minutes,  adding  water  to  make  up  for  loss  by  evapora- 
tion; or,  boil  the  same  quantity  of  the  soy  flour  for  one-half  hour  with  i  quart  of  water, 
to  which  has  been  added  a  piece  of  him,  bacon,  or  salt  pork  to  give  flavor.  Each 
ounce  of  the  flour  will  add  to  the  broth  about  13  gm.  of  protein,  and  120  calories,  or, 
in  percentages,  add  1.4  per  cent,  protein,  0.6  per  cent,  fat,  and  0.3  per  cent,  carbo- 
hydrates. A  broth  made  with  6  ounces  of  the  soy  flour  to  the  quart  would  be  half  as 
rich  in  protein  and  fat  as  steak. 

Muffins. — To  make  mufiins  from  the  soy  flour,  take  i^  teacupfuls  of  the  soy  flour, 
],i  teacup  of  wheat  flour,  i,i  teaspoonful  of  salt,  2  eggs,  i  teacupful  of  sweet  milk,  2 
rounded  teaspoonfuls  of  baking-powder,  and  i}i  tablespoonfuls  of  melted,  but  not  hot, 
butter.  Beat  well  together,  adding  the  melted  butter  last,  and  bake  in  gem  pans  in  a 
hot  oven.  This  will  make  about  1 2  muffins,  which  will  contain  about  1 50  gm.  of  pro- 
tein, and  which  will  yield  about  1800  calories,  of  which  the  carbohydrates  produce  but 
280. 

The  soy  flour,  being  nitrogenous,  requires  the  addition  of  some  wheat 
flour  in  making  muffins,  as  above.  The  mixture  of  wheat  and  soy  flours 
in  this  formula  will  contain  about  36  per  cent,  protein  and  20  per  cent, 
carbohydrates,  against  14  per  cent,  protein  and  from  60  to  70  per  cent, 
carbohydrates  in  gluten  flour.  The  proportion  of  protein  to  carbohydrates 
is  from  8  to  10  times  as  large  in  the  mixed  soy  and  wheat  flour  as  in  gluten 
flour. 

The  author  believes  that  in  this  soy  gruel  we  have  a  valuable  addition 
to  our  dietary,  and  believes  it  useful  in  typhoid  fever  and  in  many  other 
conditions. 

A  diet  conforming  to  true  nutritive  requirements  must  tend  toward  vegetable 
food  if  excess  in  proteins  is  to  be  avoided. 

There  is  less  need  for  food  in  hot  weather,  especially  for  fat,  when 
lighter  foods  and  less  calories  are  required. 

We  must  also  remember  that  the  excessive  use  of  salt  strains  the 
kidneys. 

The  following  table,  modified  from  that  of  Koenig  and  others,  gives  the 
chemic  composition  of  different  foods  and  the  heat  units  which  they 
produce. 


DIET 


l8l 


Chemic  Composition  of  Common  Food  Substances 
I.  Meals  and  Game 


Per  cent. 

nitrogenous 

(proteid) 


Beef  (very  fat) 

Beef  (lean) 

Veal  (fat) 

Veal  (lean) 

Mutton  (fat) 

Mutton  (lean) 

Pork  (fat) 

Pork  (lean) 

Westphalia  ham .... 

Salted  ham   

Smoked  beef 

Smoked  beef  tongue. 
Pulverized  meat.  .  .  . 

Sweetbread 

Chicken  (fat) 

Chicken  (lean) 

Capon 

Duck  (wild) 

Partridge 

Pigeon 

Hare 

Venison 


17.19 
20.  78 
18.88 
19.84 
14.  80 
17.11 

14  54 
20.25 

23-97 
22.32 
27. 10 

24  31 
64.50 
22.00 
18.49 
19.72 
23  32 
22.65 
25.26 
22. 14 

23 -34 
19.77 


Per  cent, 
fat 


26.38 
1-50 
7-41 
0.82 

36.39  - 
5-77 

37-34 
6.81 

36.48 
8.68 

15-35 
31.61 

5-24 
0.40 

9-34 
1.42 

3-^5 
3-II 
1-43 
1. 00 

1-13 

1 .92 


Per  cent, 
carbohydrate 
(nitrogen  free) 


0.05 


1-5° 


2.28 

I.  20 
1.27 
2-49 
2-33 

0.76 
0.19 

1 .42 


Calories 
per  100 


315-81 

99-15 

146.61 

86.97 

399-31 
123.81 
406 . 88 
146.36 
453 • 69 
173-23 
253 • 76 
393 • 64 
322.53 

93  92 
167.58 

99.10 

135-11 
131  36 
116.85 
100.02 
107 .08 
105-44 


II.  Fisk 


Eel 

Pike 

Carp 

SheU6sh 

Halibut 

Salmon 

Sardellen 

Oysters 

Fresh  herring 
Salt  herring.. 
Caviar 


Per  cent. 

nitrogenous 

(proteid) 


12.83 

18.34 
20.61 
17.09 
11.94 
15.01 
22.30 

4-9S- 
10.  II 
18.90 
31   36 


Per  cent, 
fat 


28.37 
0-51 
1.09 

34 
25 
42 
21 

37 
.  II 


16.89 
15.61 


Per  cent, 
carbohydrate 
(nitrogen  free) 


53 
•63 


0-45 
2.8s 

0.45 
2.62 

1-57 
2.23 


Calories 
per  100 


312 

83 

94 

156 

53 

132 

113 

34 

106 

247 

279 


l82 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


III.  Dairy  Products 


Cows'  milk.  .  . . 

Cream 

Buttermilk  . . . 
Whey 

Kumyss  (cows' 
milk) 

Butter 

Cheese  (cream) 

Cheese 

Eggs  (hens') . .  . 
White  of  egg. .  . 
Yolk  of  egg. . .  . 


Per  cent. 

nitrogenous 

(proteid) 


Per  cent, 
fat 


3.41  to  4.3 
3.61 

3 .  00  to  4 .  o 

0.8s 

3 -65 


0.50 
16.28 

34-99 
12.50 
12.67 
16.  24 


3.00  to  3.8 
26.75 

o. 93  to  1 . 3 
0.23 

( 

2.07  j 

\ 
0.90 
41 .  22 

II  37 

12. 10 

0.25 

31-75 


Per  cent, 
carbohydrate 
(nitrogen  free) 


Calories 
per  100 


3.70  to  4. 81 

3-52 

3 .  00  to  4 .  00 

3  03 
Lactic  acid,  o .  7 
Alcohol,  1.9 
Carbonic      acid, 

8.00 

0.50 

1 .90 

5-40 

0.50 


o.  12 


56.41  to  71.93 
276.01 

33 .  08  to  43 .  63 
18.00 

■ 

32.99 

823.10 

449 • 54 
269.06 
165  .00 

54-22 

355-99 


IV.  Cereals  and  Vegetables 


Per  cent, 
nitrogenous 

Per  cent, 
fat 

Per  cent, 
carbohydrate 

Calories 

(proteid) 

(nitrogen  free) 

6.00 

0.75 

52.00 

245.00 

6. II 

0.43 

46.00 

217-56 

0.50 

traces 

86.50 

356  -  70 

8.50 

1-25 

73.00 

345 • 78 

10.00 

2.00 

69.00 

342 . 50 

11.00 

4.60 

73  ■  30 

387.09 

6.82 

0.77 

43-72 

213.87 

9.50  to  13.0 

1. 00  to  3.0 

75-00 

356  00 
(average) 

2 .  00  to    5.0 

0.40 

4.00 

3500 

I -59 

•  20 . 00 

88.00 

2.00 

0.30 

2.50 

20.00 

1.04 

0.21 

6-74 

33-85 

550 

I  50 

76.00 

348 . 10 

19-50 

2.90 

52.00 

311.7s 

19-50 

2.00 

54-00 

319-95 

2-49 

0.58 

4-44 

33  67 

12.05 

5.26 

66.77 

338.80 

8.31 

0.81 

75-19 

323.00 

4- 83 

0.41 

6.  22 

49-05 

1.89 

0.20 

4.87 

29.52 

1.02 

0.09 

0.9s 

8.81 

Wheat  bread 

Rye  bread 

Sago 

Wheat  flour 

Rye  flour 

Cakes 

RoU 

Zwieback 

Cauliflower 

Potatoes 

Asparagus 

Carrots 

Rice 

Beans , 

Peas 

Spinach 

Oatmeal 

Barley  meal.  ... 
Brussels  sprouts. 
Cabbage  (white) . 
Pickles 


DIET 

V.  Soups  and  Beverages 


183 


Per  cent. 

nitrogenous 

(proteid) 


Per  cent, 
fat 


Per  cent. 

non-nitrogenous 

carbohydrate 


Calories 
per  100 


Meat  broth 

Meat  juice  (expressed) 

Beef-tea 

Leube's  meat  solution 

Malt  e.xtract 

Milk  soup  with  wheat  flour 

Barley  soup 

Rice  pap  with  milk 

Coffee 

Tea 

Beer 

Porter 


0.40 
6.00  to 


7.0 


0.50 
9  to  II  albu- 
min and  1.7 
to    6.5    pep- 
ton. 

8.00  to  10. c 

5.00 

8.80 
3.12 
12.38 
0.50 
0.70 


0.60 
0.50 

0.50 


3-25 
1 .00 

3.50 
5. 18 

5-25 
6.00. 


o-S 


SS-O 

II. o 

28.6 


0.3 
0.3 


7. 10 

31.20 

(average) 

6.60 

86.50 
(average) 

258.30 
112.00 
60.96 
182.61 
59-92 
50.7s 
51.00 
60.00 


VI.  Fruits,  Nuts,  and  Sugar 


Per  cent, 
free  acid 


Per  cent. 

nitrogenous 

proteid 


Chiefly  sugar 

Per  cent, 
fat 

Per  cent,  non- 
nitrogenous 
carbohydrate 

Calories 
per  100 

7  .  22 
8.24 
4.68 

29.6 

33-78 

19.18 

0-45 

7.17 

4.69 

14.36 

6.78 

29  39 
19.  22 
58.87 
31-88 

1-37 

38.34 
93  33 
99-75 

192. II 
382.65 
408 . 97 

73.22 

305.22 

Apples 

Pears 

Plums 

Peaches 

Apricots. .  .  . 

Grapes 

Strawberries, 
Chestnuts.. . 
Cane-sugar. . 
Beet-sugar. . 
Honey 


0.82 
o.  20 
1.50 
0.92 
1. 16 
0.79 
0-93 


35 


For  the  determination  of  the  calorie  value  of  each  kind  of  food,  the 
number  of  grams  of  albumin  must  be  multiplied  by  4.1,  the  grams  of  carbo- 
hydrate by  4.1,  and  the  grams  of  fat  by  9.3,  and  the  multiples  added  will 
give  the  total  calories  as  already  described. 

The  following  diet-lists  of  von  Noorden^  demonstrate  the  method  of 
calculating  calorie  values,  and  will  be  found  useful  to  fulfil  their  indications: 


1  Berl.  Klinik,  1838,  J.  55- 


184  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

I.  A  Chiefly  Milk  Diet  with  Addition  of  Carbohydrates  in  Liquid  Form 


Albumin 
(per  cent.) 

Fat 
(per  cent.) 

Carbohydrate 
(per  cent.) 

Calories 
per  100 

Milk,  1700  c.c 

70.2 
10. 0 

7.0 

66.3 

5-5 

69.7 
30.0 

40.0 

129s 
164 

244 

Soup  of  tapioca  flour,  30  gm. 

and  10  gm.  albumose^ 

Soup   of  40  gm.   wheat   flour, 

with  some  of  the  milk,  10  gm. 

sugar,  and  one  egg 

Total 

87.2 

71.8 

1397 

1703 

^  Ten  gm.  albumose  is  contained  in  90  c.c.  (3  ounces)  of  Denayer's  peptone  prepa- 
ration, in  22  gm.  (3vss)  of  Kemmerich's,  or  in  30  gm.  (i  ounce)  of  Koch's. 


II.  A  Chiefly  Milk  Diet  with  the  Addition  of  Carbohydrates  and  Fat  in  Mushes  and  Soups 


Albumin 
(per  cent.) 

Fat 
(per  cent.) 

Carbohydrate 
(per  cent.) 

Calories 
per  100 

Good  milk,  1500  cc 

62 

17 
7 

58. 5 

13s 
5-5 

63 

IS 
90 

1056 

257 
398 

Soup  of  15  gm.  sago,   10  gm. 
butter,      I      egg,      10      gm. 
albumose 

Pap  of  80  gm.  corn  flour,  i  egg, 
10  gm.  sugar  (two  meals) .... 

Total 

86 

77-5 

168 

1711 

III.  Milk  Diet  with  Addition  of  Solid  Food,  Pastry,  and  Broths,  leaving  little  Residue 


' 

Albumin 
(per  cent.) 

Fat 
(per  cent.) 

Carbohydrate 
(per  cent.) 

Calories 
per  100 

Milk,  1250  c.c 

Meat  broth  with  i  egg,  10  gm. 
of  butter,  50  gm.  of  fine 
toasted  wheat  bread  (or  soft- 
ened)   

Cakes  70  gm.,  butter  15  gm.  . . 

Soup  of  30  gm.  tapioca  flour,  i 
egg,  10  gm.  butter 

SI 

10 
S 

7 

49 

14 

12 

14 

S2 

30 
SO 

30 

878 

294 
337 

282 

Total 

73                     89 

162 

1791 

DIET  185 

IV.  Milk  with  Tender  Meat,  Solid  Food  {Pastry),  Butter,  and  Soups 


Albumin 
(l>er  cent.) 

Fat 
(per  cent.) 

Carbohydrate 
(per  cent.) 

Calories 
per  100 

Spring  chicken,  100  gm 

Mashed  potatoes,  100  gm 

Two  eees 

19.6 

2.0 

14. 1 

7.0 

193 
510 

2.8 

4.0 
II. 0 

0.5 

23.0 

2.1 

49.0 

20 

55 

52 

106.4 
127.4 
160    I 

Toasted  wheat  bread,  100  gm.. 
Butter,  30  gm 

258.8 
213.9 
106.4 

878.0 

Trout,  100  gm 

Milk,    1250  c.c.  and  soups  in 
addition..         

Total 

113. 0 

92.4 

127 

1851 .0 

V.  Abundant  Non-irritating  Diet 


Albumin 
(per  cent.) 

Fat 
(per  cent.) 

Carbohydrate 
(per  cent.) 

Calories 
I>er  100 

Tender  meat,  250  gm.' 

Cacao,  20  gm 

49 
4 

21 
8 
7 
4 

•       SI 

7.0 

6.0 

16.0 

I.O 

OS 

2-3 

44.0 
49.0 

8 

75 
55 
36 

40 
40 
20 
52 

266.0 
105.0 
235   0 
349  4 
258.7s 
187.0 
407.0 
164.0 
164.0 
82.0 

Three  eegs^ 

100  gm.  Zwieback 

100  gm.  wheatbread 

50  gm.  cakes.. . 

50  gm.  butter' 

40  gm.  tapioca  flour* 

40  gm.  corn  flour  (maizena) . . 
20  em.  suear* 

1250  cc.  milk* 

878.0 

Total 

144 

125.8 

326 

3096.15 

Diet  Scales. — A  convenient  diet  scale  has  been  devised  by  Stuart 
Hart/  of  New  York.  It  is  depicted  in  Fig.  123.  The  scale  has  a  total 
capacity  for  1000  gm.,  with  subdivisions  of  20  gm.  each.  The  dial 
can  be  rotated  to  any  point  desired,  so  that  the  zero  point  can  be 
brought  to  correspond  to  the  tip  of  the  dial  pointer.  For  example, 
suppose  the  food  prescription  consists  of: 

Meat zoo  gm. 

Potatoes 80  gm. 

String-beans 140  gm. 

Wheat  bread 60  gm. 

^  Meat  of  various  kinds,  finely  chopped,  raw  or  broiled  in  butter,  or  roasted,  cold 
or  hot,  given  in  two  meals. 

'  Egg  in  cocoa,  one  in  soup  and  one  raw  or  soft  boiled. 

•  Butter  for  starchy  foods,  soup,  etc. 

•  Tapioca  flour  to  thicken  soup. 

'  Sugar  for  cocoa  and  cornmeal  pudding. 

•  Milk  for  cocoa,  pudding,  and  to  drink. 
'  Jour.  Amer.  Med.  Assoc.,  Aug.  7,  1909. 


i86 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Place  an  empty  plate  on  the  scale  and  rotate  the  dial  until  the  zero 
point  is  opposite  the  end  of  the  pointer.  Add  meat  until  the  pointer 
indicates  loo  gm. ;  then  rotate  the  dial  again  until  zero  is  opposite  the 
pointer;  then  add  potatoes  until  80  gm.  is  indicated,  and  so  on,  so  that 
each  time  the  zero  point  on  the  dial  is  brought  opposite  the  pointer. 

Digestibility  of  Food. — ^We  may  say  that  an  article  of  diet  is  easily 
digestible  if  it  makes  small  demand  on  the  secretory  and  motor  functions 
of  the  stomach,  if  it  is  readily  absorbed,  and  causes  no  subjective  dis- 
turbance. The  scale  of  digestibility  of  foods  has  been  arranged  according 
to  the  length  of  time  that  they  remain  in  the  stomach,  the  motor  and  secre- 
tory functions  in  the  healthy  stomach 
acting  together,  and  hence  the  length 
of  time  the  material  remains  in  the 
organ  indicates  its  digestibility;  good 
motor  power  for  a  definite  food  shows 
food  digestion.  In  pathologic  condi- 
tions the  rule  is  not  as  absolute,  for 
either  secretory  or  motor  functions 
may  be  perverted  alone  or  together, 
and  sometimes  in  opposite  directions. 
Gastric  digestion  may  also  be  vicari- 
ously assumed  by  the  intestines. 

Leube's  experiments  were  con- 
ducted with  digestion  in  diseased 
stomachs,  and  from  these  he  con- 
structed his  diet  scale  of  foods  ac- 
cording to  their  digestibility.  It 
especially  forms  the  basis  of  the  diet  of  ulcer  (Leube's  method),  and  is 
valid  in  many  other  conditions. 

Leube's  Diet  Scale. — Diet  i. — With  much  reduced  digestion,  the 
following  are  most  easily  digested:  bouillon,  meat  solutions,  such  as 
Leube- Rosenthal's;  milk;  raw,  soft-boiled,  or  poached  eggs;  zwieback; 
water,  acidulous  waters  (Apollinaris,  Seltzer). 

Diet  2. — ^Less  digestible  are  boiled  calves'  brain,  boiled  thymus,  boiled 
chicken  and  pigeon,  boiled  calves'  feet  (with  some) ;  gruels,  milk,  mushes 
made  with  tapioca  and  beaten  white  of  egg. 

Diet  3. — If  diet  2  is  digested,  then  these  can  be  given:  Raw  beef 
(chopped  fine)  or  scraped  meat  with  a  dull  spoon,  and  roast  meat  scrapings 
in  fresh  butter;  raw  ham  (chopped  fine);  a  little  mashed  potato;  stale 
white  bread  and  a  small  amount  of  coffee  or  tea  with  milk. 

Diet  4. — Roast  chicken;  roast  pigeon,  venison;  partridge;  roast  beef, 
medium  to  raw  (particularly  cold);  veal  (leg);  pickerel;  boiled  shad; 
macaroni;  bouillon  with  rice.  Trout  are  hard  to  digest.  Small  quantities 
of  wine  one  or  two  hours  before  eating.  Gravies  are  contraindicated. 
Young  and  finely  chopped  spinach  is  best.  Asparagus  may  be  tried,  but 
Leube  considers  it  risky.  After  the  fourth  diet  the  food  is  gradually 
increased,  but  very  gradually.  Vegetables,  salads,  preserves,  and  fruits 
should  be  refrained  from  for  a  long  time.  A  baked  apple  is  one  of  the  first 
of  these  that  can  be  taken. 


Fig.  123. 


-A  food  scale  with  an  adjust- 
able dial. 


DIET  187 

Penzoldt  has  formulated  a  scale  of  digestibility  for  the  normal  stomach. 

Various  Food-stuffs. — It  is  important  to  remember  that  we  can  replace 
the  albumin  in  food  by  carbohydrates,  and  at  times  by  the  fats,  though 
the  latter  are  not  always  well  tolerated.  Many  of  the  legumes,  such  as 
peas,  lentils  and  beans,  contain  a  large  amount  of  protein  as  well  as  carbo- 
hydrates, which  often  is  of  advantage.  When  beans  are  soaked  in  soda 
and  water  and  parboiled  to  remove  the  skins,  less  gaseous  production 
(flatulence)  results.  The  entire  removal  of  the  skin  of  peas,  beans  and 
lentils  is  recommended  in  the  case  of  persons  with  whom  they  disagree. 
The  legumes  have  been  extensively  used  among  the  poorer  classes  in  many 
races  to  replace  meat,  thus  the  frijole  (native  bean)  in  Mexico,  lentils 
among  the  Bedouins,  Hindoos,  etc. ;  among  the  Maine  lumbermen,  baked 
beans  furnished  20  to  ^s  P^r  cent,  of  the  total  protein.  A  pound  of  dried 
peas  costing  8  cents  contains  as  much  edible  protein  as  is  found  in  an 
equal  weight  of  meat. 

Cooking  oj  Dry  Legumes. — The  water  should  not  be  hard  {i.e.,  im- 
pregnated with  lime  and  magnesia  salts)  since  the  legumin  of  the  seeds 
forms  insoluble  compounds  with  these  salts.  Rain  water  is  preferable. 
One  can  employ  distilled  water  or  boil  the  water  before  using  and  then 
add  one  teaspoon  of  bicarbonate  of  soda  to  a  gallon  of  this  water  and 
boil  the  legumes  therein.  Soaking  the  legumes  in  fresh  water  for  a  number 
of  hours  before  cooking,  removes  the  bitter  taste — particularly  in  lentils. 
Though  the  dried  pea  or  bean — soaked  overnight  in  water  may  be  cooked 
soft  enough  in  one  and  one-half  to  two  hours  to  be  passed  through  a 
sieve — individual  grains  can  still  be  detected.  It  is  therefore  preferable  to 
cook  much  longer.  Pork  and  beans  for  example  baked  all  night  in  the  New 
England  brick  oven  or  pea  soup  cooked  for  twelve  hours  are  preferable. 
Though  the  protein  in  beans  is  in  large  amount,  they  contain  a  small 
amount  of  fat  and  the  addition  of  fat  in  the  form  of  salt  pork  or  butter 
improves  the  flavor  and  makes  a  better  balanced  article  for  diet.  One  of 
the  best  methods  is  to  prepare  the  dried  pea  or  lentil  in  a  thick  soup  or 
puree.  In  the  Mediterranean  countries,  the  pea  and  lentil  are  roasted. 
Peas,  beans  and  lentils  are  made  into  flour  and  mixed  with  wheat  flour  for 
baking.  Finely  ground  peas,  beans  and  lentils  form  the  basis  of  many 
soup  tablets  and  have  been  used  extensively  by  armies  and  explorers, — 
for  example  the  "pea  sausage"  consisting  of  finely  ground  pea  and  lentil 
flour  well  cooked — evaporated  and  mixed  with  a  proportion  of  bacon  with 
seasoning  and  some  preservative.  Peanut  butter — which  contains  more 
protein  and  less  fat  than  ordinary  butter  may  at  times  be  of  value. 
In  many  cases  the  food  should  be  concentrated,  nourishing,  and  finely 
divided,  so  as  not  to  irritate  the  organ. 

Milk  is  excellent  in  some  cases,  but  in  ulcer,  too  large  quantities  to 
secure  sufficient  nourishment  at  least  3  liters  (1770  calories),  would  have 
to  be  given,  which  would  tend  to  overdistend  the  organ. 

Moreover,  raw  milk  remains  in  the  stomach  longer  than  some  other 

forms  of  nutriment,  and  when  given  alone,  may  coagulate,  and  with  some 

disagrees.     In  some  experiments  at  the  Manhattan  State  Hospital,^  in 

cases  of  dilatation  of  the  stomach,  it  was  conclusively  shown  that  this  organ 

1  Medical  Record,  June  20,  1908. 


1 88  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

emptied  itself  with  greater  rapidity  in  proportion  to  the  dilution  of  the  milk 
with  water.  It  is,  therefore,  preferable  to  give  smaller  quantities  of  milk 
and  not  to  administer  it  alone,  but  diluted  with  barley-water,  for  example, 
or  some  other  amylaceous  material,  such  as  rice-water  or  decoctions  of 
tapioca,  maizena,  etc.  One  can  add  material  such  as  raw  eggs  to  increase 
the  calorie  value,  a  large  amount  of  nutrient  in  small  bulk,  as  described 
under  the  treatment  of  gastric  ulcer.  Buttermilk  has  small  nutritive 
value.  Kefir,  koumiss,  bacillac,  lactone-buttermilk,  fermillac  and  mat- 
zoon  are  often  useful. 

Meat  broth  and  bouillon  have  little  nutritive  value,  while  beef-tea  and 
expressed  beef-juice  are  of  some  service.  It  has  been  demonstrated, 
however,  that  bouillon  or  meat  soup  taken  early  in  the  meal  soon  reach 
the  pylorus  and  act  as  secretagogues,  producing  gastrin,  inciting  a  flow  of 
gastric  juice.     They  aid  thus  in  awakening  dormant  secretory  glands.^ 

Beef-juice  is  best  made  from  the  rump  of  beef,  cut  in  dice,  cooked  for 
live  to  ten  minutes,  and  then  the  beef-juice  expressed  and  pepper  and 
salt  added. 

Gelatinous  articles  of  food,  such  as  gelatin  in  solution,  jellies,  calves' 
feet,  etc.,  are  easily  digested,  as  are  soups  containing  chicken  or  calves' 
brain  finely  macerated  and  forced  through  a  sieve.  Gelatin  does  not 
produce  indican,  which  is  of  great  advantage. 

Shellfish,  pike,  halibut,  and  carp  contain  the  least  fat  and  are  digestible. 

Carbohydrates  should  be  well  masticated  and  carefully  insalivated. 
If  they  contain  much  cellulose,  they  are  not  so  readily  digested  and  should 
be  ground  thoroughly.  If  there  is  stagnation  and  so  danger  of  fermen- 
tation, care  in  their  use  should  be  exercised. 

Ordinary  bread  (rye  or  domestic)  is  not  so  good.  Zweiback,  toast, 
maizena,  tapioca,  oatmeal,  and  Lofflund's  Kindermehl  are  best. 

Aleuronat  flour  (Ebstein)  contains  So  per  cent,  albumin.  Leguminose 
(Hartenstein's),  Liebig's  maltoleguminose,  and  Knorr's  preparations  are 
excellent.  American  veal  has  been  found  by  experience  to  be  not  very 
digestible. 

Fat,  in  the  form  of  butter,  egg  yolk,  and  cod  liver  oil  contain  a  growth 
promoting  ingredient  according  to  Mendel^  which  appears  to  be  more  or 
less  completely  wanting  in  other  fats  of  animal  or  vegetable  origin.  Fats 
inhibit  gastric  secretion,  and  this  fact  may  be  taken  advantage  of  in  the 
treatment  of  hypersecretion,  and  hyperchlorhydria.  Butter  (gm.  50  to 
100  c.c.  daily)  usually  agrees.     This  is  average  normally  ingested. 

Olive  oil  improves  nutrition,  helps  bowel  action  and  diminishes  gastric 
hj^eracidity.     It  also  acts  well  in  ulcerated  conditions. 

Coffee  and  tea  may  be  given  in  moderate  amounts  in  many  cases,  but 
considerably  diluted. 

Water. — The  question  is  often  asked  as  to  the  propriety  of  water 
drinking  at  meals.  Modern  physiology  and  the  a:-ray  have  taught  us 
that  water  passes  rapidly  from  the  stomach  if  the  organ  is  not  dilated 
(atonic)  or  ptosed,  i.e.,  is  normal.     It  does  not  interfere  with  gastric  diges- 

*  The  relation  of  the  Food-stuflFs  to  Alimentary  Functions  (Mendel),  Amer.  Jour. 
Med.  Sci.,  Oct.,  1909. 

*  Jour.  A.  M.  A.,  Sept.  5,  1914. 


DIET  189 

tion.  Abstention  from  water  tends  to  constipation  and  the  production 
of  intestinal  putrefaction,  Hattrem  and  Hawk  report  that  the  ingestion  of 
500  c.c.  (a  moderate  amount)  to  1000  c.c.  (a  copious  amount)  of  water  at 
meals  progressively  decreased  intestinal  putrefaction  as  measured  by  the 
indican  output.  It  also  stimulates  gastric  secretion.^  The  writer  believes 
that  the  average  healthy  adult  should  drink  about  3cx>-40o  c.c.  water  at 
meals,  slowly.     It  should  not  be  icy  cold. 

Alcohol. — Wines  are  recommended  by  many  as  a  mild  stimulant  to  the 
stomach  in  certain  cases,  but  from  personal  experience  I  advise  against 
their  use.  There  are  other  remedies  which  give  better  results.  The 
writer  does  not  advocate  the  use  of  liquor  in  gastro-intestinal  diseases. 
When  stimulants  are  necessary,  accurate  dosage  with  cardiac  stimulants 
he  believes  preferable. 

General  Rules. — The  teeth  should  be  kept  in  good  condition;  thorough 
mastication  and  insalivation  are  important,  and  a  brief  period  of  rest 
after  meals  should  be  advised  both  in  health  and  disease.  Regularity  of 
meals  should  be  enjoined. 

Method  of  Feeding  to  Spare  the  Stomach. — The  Council  on  Pharmacy 
and  Chemistry  of  the  American  Medical  Association  has  performed  an 
excellent  work  in  demonstrating  the  uselessness  of  many  of  the  proprietary 
foods.  Some  of  these  foods  may  at  times  be  of  some  temporary  assistance 
when  added  to  other  liquid  nourishment,  particularly  when  it  is  necessary 
to  administer  nutriment  in  soluble  or  easily  digested  form.  Appended  is 
a  short  list: 

Hemmerich's  peptone,  somatose,  tropon,  panopeptone,  Koch's 
peptone.  Brand's  meat  preparations,  Valentine's  meat  juice,  Liebig's 
soup,  Gartner's  fat  milk  and  malted  milk,  and  malt  soup.  Keller's  formula 
for  malt  soup  is  as  follows:  Milk  11  oz.,  wheat  flour  1%  oz.,  malt  soup 
extract  3^  oz.,  water  22  oz.  Boil  the  flour  in  water  for  20  minutes  and 
then  add  other  ingredients.  For  diarrheal  conditions  particularly  in 
young  infants  Hoag's  formula  is  preferable  (American  Med.,  Sept.,  1915). 
Skimmed  milk  10  oz.,  flour  (prepared  barley  or  wheat)  2  teaspoons,  malt 
soup  extract  i  teaspoon,  water  18  oz.  Mix  flour  and  water  in  one  bowl 
(making  a  careful  paste  of  the  flour  by  adding  a  little  milk  and  rubbing  this 
to  prevent  lumps).  The  malt  and  water  are  mixed  in  another  bowl  and 
the  two  mixtures  are  put  together  in  a  double  boiler  and  boiled  slowly 
30  minutes.  Add  boiled  water  to  make  28  oz.  and  divide  into  7  bottles 
(7  feedings).  It  may  be  necessary  to  add  a  little  alkali  such  as  lime 
water  or  soda  bicarbonate. 

Leube-Rosenthal  Meat  Solution. — Chop  i  kilo  of  beef  into  fine  pieces, 
mixing  it  with  water  (i  liter),  and -add  20  gm.  of  pure  hydrochloric  acid 
and  boil  mixture  ten  to  fifteen  hours  in  a  Papin  pot.  The  mass  obtained 
is  crushed,  boiled  fifteen  hours  longer,  neutralized  with  pure  sodium 
carbonate,  and  evaporated  to  a  mushy  consistence.  It  is  digestible,  but 
contains  relatively  small  quantities  of  peptone. 

Dibove's  Meat  Powder. — Roast  finely  chopped  lean  beef  on  tin  plates 
until  it  is  entirely  desiccated.     Powder  in  a  mortar. 

Haggard. — Cut  lean  meat  into  narrow  strips,  place  for  a  few  minutes 
^Jour.  Amer.  Chem.  Soc,  Jan.,  1914. 


IQO  DISEASES    OF   THE    STOMACH   AND   INTESTIKES 

in  hot  fat  or  lard  until  surface  is  browned,  then  place  on  a  sieve  for  a  short 
time.  Fat  is  allowed  to  drip  off,  and  meat  is  dried  twenty-four  hours  in  a 
baking  oven  at  a  moderate  temperature,  then  ground  to  powder  in  a 
coffee-mill.  As  a  matter  of  interest  in  view  of  the  high  cost  of  living  I 
would  advise  my  readers  to  study  Graham  Lusk's  article,^  ''Analysis  and 
Cost  of  Ready  to  Serve  Foods." 

Duodenal  Alimentation. — Einhorn^  makes  use  of  his  duodenal  pump 
for  forced  feeding.  This  instrument  he  employs  for  aspirating  the 
duodenal  contents,  and  for  feeding  simply  reverses  the  process.  The 
patient  swallows  a  small  perforated  hollow  bulb  to  which  a  thin  tube  is 
attached.  After  the  bulb  enters  the  duodenum,  the  instrument  is  left 
in  situ  for  eight  to  twelve  days,  liquid  nourishment  being  forced  in  every 
two  hours  from  7  a.  m.  to  9  p.  m. 

Analysis  of  results  of  three  cases  shows  that  case  i  left  hospital  with 
gain  of  }i  pound,  but  not  free  of  complaint.  Case  2  received  medication 
by  mouth  during  duodenal  alimentation,  and  later  mouth  and  duodenal 
feeding  were  both  employed,  and  finally  mouth-feeding  combined  with 
lavage.  The  case  was  ultimately  cured  of  gastroptosis.  Case  3,  one  of 
subacidity  and  nervous  vomiting,  lost  i  pound  during  duodenal  alimen- 
tation, but  vomited  less,  and  on  resumption  of  mouth-feeding  the  vomiting 
became  more  severe.  No  judgment  can  be  formed  from  a  neurotic  case. 
He  reports  more  recently  favorable  results  by  this  method  in  feeding  cases 
of  gastric  or  duodenal  ulcer.  Claims  are  also  made  as  to  the  value  of  this 
method  in  reducing  an  atonically  dilated  stomach  and  in  the  reduction  of 
an  enlarged  liver  (cirrhosis).  The  theory  being  advanced  that  the  portal 
system  is  overburdened  by  the  more  sudden  addition  of  fluid  from  the 
upper  digestive  system  (presumably  from  the  gastric  vessels  from  absorp- 
tion from  the  stomach)  and  that  this  is  avoided  by  duodenal  alimentation. 
Einhorn  believes  the  above  and  that  also  faulty  metabolic  products  de- 
range the  upper  digestive  tract.  Unfortunately,  this  explanation  is  un- 
tenable, as  Meltzer  has  experinaentally  demonstrated  that  but  little  fluid 
is  absorbed  by  the  stomach  and  it  has  been  conclusively  demonstrated  by 
the  radiologists  that  fluids  immediately  leave  that  organ.  The  stomach 
chiefly  prepares  its  food  for  subsequent  digestion  in  the  intestines.  More- 
over, the  portal  vein  drains  both  stomach  and  small  intestines.  In  cases  of 
ectasy  with  pyloric  stenosis  or  spasm,  the  instrument  often  will  not  enter 
the  duodenum;  considerable  pharyngeal  irritation  and  discomfort  are  pro- 
duced; it  is  difficult  to  force  the  liquid  nourishment  through  the  fine  tube; 
there  is  no  improvement  in  nutrition  (gain  in  weight),  and  persistent  irri- 
tation from  a  foreign  body  the  writer  beHeves  harmful  in  pyloric  or  duo- 
denal ulceration.  Unpleasant  distention  also  frequently  occurs.  Intelli- 
gent employment  of  nutritive  enemata,  combined  with  lavage,  forced 
stomach-feeding  (gavage),  and  posture  on  the  right  side  after  each  feeding 
are  indicated  in  cases  of  stenotic  ectasy;  as  temporary  measure  preparatory 
to  operation;  the  Lenhartz  treatment  in  patients  with  gastric  ulcer  will 
improve  the  patient's  condition  and  increase  the  weight.     The  writer  does 

1  Jour.  A.  M.  A.,  May  22,  1915. 
'  Med.  Record,  July  16,  1910. 


DIET  191 

not  recommend  the  method  of  duodenal  alimentation,  for  the  reasons  given 
and  because  he  has  had  no  good  results  from  it. 

Rectal  Alimentatioii. — General  Rides. — One  must  remember  that  but 
little  calorie  valtce  (from  300  to  600  units),  is  obtained  by  rectal  alimentation 
and  that  this  measure  is  only  a  temporary  means  of  tiding  over  an  emergency 
— to  save  the  stomach.  The  bowels  should  be  emptied  by  enema;  injection 
of  the  nutritive  enema  should  be  given  with  the  patient  on  the  left  side, 
through  a  colon-tube  several  hours  later;  the  temperature  should  be  about 
ioo°F.  (warm).  A  folded  towel  should  be  pressed  against  the  anus,  and 
the  buttocks  pressed  together  for  at  least  fifteen  minutes  after  the  injection. 

Milk  should  always  be  peptonized,  and  alcohol,  if  injected,  should  not 
be  stronger  than  i  :  6  in  the  fluid  enema.  The  addition  of  a  small  amount 
of  salt  aids  absorption.  Dextrose  is  readily  absorbed.  Occasionally  it 
may  be  necessary  to  add  a  few  drops  of  tincture  of  opium  if  there  is  much 
irritation.  Raw  eggs  are  readily  absorbed.  Peptone  and  somatose  are 
excellent  additions.  No  more  than  8  ounces  (250  c.c.)  should  be  given 
at  an  injection.  It  can  be  administered  four  or  five  times  a  day.  If  the 
bowel  is  irritable,  smaller  quantities  should  be  employed.  The  patient 
should  remain  quiet  for  one-half  hour  after  the  injection. 

Ewald  suggests  3  to  5  raw  eggs,  mixed  with  150  c.c.  of  water  and  30 
gm.  of  grape-sugar,  and  a  small  amount  of  common  salt. 

Boas  uses  250  gm.  milk;  yolks  of  2  eggs;  salt,  tablespoon  of  red  wine; 
tablespoon  of  Kraftmehl. 

I  have  found  the  following  useful:  milk  (peptonized);  125  c.c;  2  raw 
eggs  beaten  up;  water  q.  s.  ad  250  c.c.  (8  ounces),  grape  sugar  gm.  30,  and 
a  little  salt.     Modifications  will  readily  suggest  themselves. 

Anematose  (Fairchild). — This  preparation,  dispensed  in  i -ounce 
vials,  consists  of  60  per  cent,  by  weight  of  pure  nutritive  solids.  Its 
approximate  composition  comprises  nitrogenous  substances  (beef  and 
wheat),  12  per  cent.,  wheat  carbohydrates,  46  per  cent.,  ash  (phosphates, 
etc.),  2  per  cent.  It  is  bottled  in  sterile  vials.  Anematose  is  especially 
prepared  for  use  as  a  nutritive  enema,  about  2  ounces  of  water  being 
added  before  injection.  Raw  eggs  may  be  added.  The  preparation  is 
soluble  and  readily  absorbed,  and  the  author  believes  it  a  valuable  adjunct 
when  prolonged  rectal  aUmentation  is  required.  It  is  convenient  for  gen- 
eral use. 

Boas^  suggests  the  use  of  nutrient  suppositories  made  of  crystallized 
egg-white  with  a  pinch  of  salt,  dextrin,  fat,  and  cocoa-butter.  Each 
suppository  contains  20  per  cent,  water,  2  per  cent,  salts,  20  per  cent, 
fats,  ;^;^  per  cent,  carbohydrate,  and  23  per  cent,  of  protein,  and  has  a 
value  of  46.2  calories.  He  administers  them  four  times  a  day.  The 
nourishment  seems  insufficient  to  the  writer,  but  the  method  may  be  tried 
if  nutrient  enemata  cannot  be  retained. 

Leube^s  Meat  Pancreas  is  Often  Voluble. — ^To  150  to  300  gm.  of 
scraped  and  finely  chopped  beef  add  50  to  100  gm.  of  pancreas  from 
cow  or  hog,  free  from  fat,  and  finely  chopped. 

The  two  substances  are  placed  in  a  dish,  and  150  c.c.  of  lukewarm 

*  Berlin,  klin.  Wochenschr.,  April  4,  1910. 


192  DISEASES    or    THE    STOMACH.    AND    INTESTINES 

water  are  added,  and  the  mixture  stirred  until  it  forms  a  thick,  mushy 
mass. 

If  fat  is  also  to  be  digested,  add  25  to  50  gm.  of  fat.  Inject  with  a 
pressure  syringe. 

Enemata  of  normal  saline  solution — i  dram  (4.0)  salt  to  i  pint  (500 
c.c.)  of  water — are  of  value  for  thirst,  or  administered  at  a  temperature 
of  1 10°  to  1 2o°F.  as  a  stimulant.  If  this  quantity  is  not  retained,  a  smaller 
amount  should  be  employed.     Proctoclysis  is  useful. 

Hypodermic  Nutrition. — Hypodermoclysis  with  half  to  i  pint  of 
normal  salt  solution  is  of  value  to  supply  fluid  to  the  body.  Sterile 
almond  oil  might  be  given  three  times  daily  subcutaneously  in  extreme 
emaciation  for  a  brief  period. 

Leube  recommends  as  much  as  50  to  100  gm.  of  bland  sterile  olive  oil 
afa  time,  injected  subcutaneously.  MilP  recommends  oil  of  lard,  cocoanut 
oil,  peanut  oil,  etc.,  made  up  into  an  emulsion  with  egg  lecithin,  as 
being  least  irritating.  As  a  rule  the  writer  does  not  employ  fats  by  this 
method.  The  subcutaneous  use  of  peptones  and  albumoses  is  harmful, 
as  the  method  of  subcutaneous  injection  of  protein  in  human  beings  has 
not  been  perfected  as  yet;  though  Heuriques  and  Anderson  have  injected 
a  solution  of  muscle  protein  acted  on  by  trypsin  and  erepsin  and  combine 
with  sodium  acetate,  glucose  and  inorganic  salts  into  dogs  and  goats,  the 
nitrogen  equilibrium  being  preserved  and  weight  increased  in  some  cases. 

Parenteral  nutrition  by  means  of  the  injection  of  glucose  by  hypoder- 
moclysis or  infusion  may  be  of  value  to  increase  the  resisting  power  of  the 
patient  in  the  course  of  post-operative  feeding  or  to  prevent  or  treat  extreme 
shock.  As  much  as  loo-i  20  gm.  (400-500  calories)  can  be  given  in  twenty- 
four  hours.  Subcutaneously  in  a  2  per  cent,  to  5  per  cent,  solution  or 
intravenously  2.25  per  cent,  to  5  per  cent,  to  7  per  cent.  For  practical 
purposes  43^  per  cent,  of  glucose  in  distilled  water  is  an  isotonic  solution 
and  suitable  for  hypodermoclysis.  For  infusion  it  should  be  given  with 
a  saline  solution  or  sodium  carbonate.  It  is  then  necessary  to  decrease 
the  strength  of  the  sugar  solution.  If  given  slowly,  however,  a  5  per  cent, 
glucose  solution  and  >^  of  i  per  cent,  sodium  carbonate  solution,  though 
hypertonic,  can  be  given  with  safety,  though  some  advise  a  2.25  per  cent. 
I  prefer  administration  by  hypodermoclysis. 

Inunctions  with  preparations  of  oil  or  lanolin  may  at  times  be  of 
service. 

Gavage,  or  forced  feeding  through  the  stomach-tube,  is  referred  to 
under  Lavage  through  the  nasal  route. 

DIET  IN  DISEASE 

General  principles  will  be  enumerated. 

In  acute  diseases  of  the  stomach,  as  in  acute  gastritis,  the  indication  is  to 
spare  the  organ  as  much  as  possible.  In  some  cases  no  food  is  admin- 
istered by  mouth  for  several  days  and  rectal  feeding  is  employed.  If 
food  is  administered,  it  should  be  given  in  small  quantities  at  first  and  in 
liquid  form — weak  broths,  bouillon,  barley-water,  a  small  quantity  of 

^Arch.  Int.  Med.,  vii,  694,  191 1. 


DIET  193 

water.  They  should  be  neither  excessively  hot  nor  cold.  Peptonized 
milk,  milk  and  lime-water,  white  of  raw  egg  beaten  up;  later,  toasted 
bread,  soft-boiled  eggs,  etc.,  and  a  gradual  return  to  full  diet. 

Ulcer  of  the  Stomach. — In  this  condition  both  mechanic  and  chemic 
irritation  of  the  stomach  should  be  avoided.  Albumin  solutions  and 
finely  divided  protein  material  are  indicated,  such  as  milk,  beef-juice, 
somatose,  and  tropon. 

Einhorn  allows  barley-,  oatmeal-,  or  rice-water  in  the  early  treatment. 
Raw  eggs  beaten  up  aid  in  binding  the  free  acid.  Dextrose  and  butter 
aid  nutrition  and  lessen  acidity.  Starch  in  any  great  quantity  is  not  well 
borne  on  account  of  the  acidity. 

Leube  avoids  all  stomach  feeding  for  several  days  after  the  hemorrhage, 
employing  nutritive  enema;  while  Lenhartz  feeds  immediately,  binds  the 
free  acid,  and  endeavors  to  rapidly  improve  nutrition.  Gelatin  solutions 
are  of  value  in  these  cases. 

Chronic  Diseases  of  the  Stomach. — In  the  chronic  diseases  it  is 
extremely  important  to  see  that  sufficient  quantity  of  food  is  taken  and 
to  improve  the  nutrition  of  the  patient,  as  frequently  subnutrition  is 
present. 

Carcinoma. — In  malignant  disease  of  the  stomach  or  its  orifices  little 
can  be  accomplished  by  diet  alone.  The  patient  should  receive  frequent 
meals  in  small  quantities,  liquid  or  pultaceous  in  form.  This  is  advisable, 
even  if  the  cancer  is  so  situated  as  not  to  interfere  much  with  the  motor 
function.  I  have  seen  cases  improve  temporarily  in  nutrition.  Radical 
or  palliative  operation  is  indicated. 

Benign  Stricture. — Stricture  of  the  cardia  can  at  times  be  dilated  with 
bougies;  operation  may  be  required;  with  pyloric  stricture  perfect  recovery 
often  follows  operation.  With  benign  pyloric  stenosis,  hyperacidity,  at 
times  with  hypersecretion,  and  ectasia  are  present.  The  indications  in 
these  cases  are  to  administer  liquid  or  mushy  foods,  chiefly  of  albuminous 
type.  There  are  relative  motor  insufficiency  and  increased  secretion. 
Starchy  food  in  quantity  is  not,  therefore,  well  borne. 

The  gastric  secretion,  motility,  and  sensibility  of  the  stomach  must  be 
studied  in  every  case. 

When  there  are  disturbances  of  the  motor  function,  food  should  be  given 
so  prepared  that  it  will  be  most  easily  evacuated  from  the  stomach,  as  in 
liquid  or  pultaceous  form. 

Among  the  disturbances  of  gastric  secretion  we  have  hyperacidity 
and  hypersecretion  (an  increase  in  the  secretory  function) ;  and  subacidity 
and  anacidity,  an  impairment  of  secretion.  Motor  disturbances  may 
complicate  any  of  these  conditions,  and  sensory  disturbances  are  most 
frequent  in  the  first  class. 

In  the  hyperacid  forms,  a  diet  should  be  selected  which  stimulates 
hydrochloric  acid  secretion  as  little  as  possible  and  at  the  same  time 
combines  with  it.  Abundant  albuminous  diet  should  be  administered, 
with  hyperacidity,  in  coarse  form  if  the  motor  function  is  intact,  otherwise 
in  liquid  or  mushy  form.  With  hypersecretion,  smaller  and  more  frequent 
meals  are  indicated,  and  fluids  should  be  limited.  Carbohydrates  in  any 
quantity  are  not  well  borne,  though  their  digestion  is  better  with  h3Tper- 
13 


0:94  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

acidity  than  with  hypersecretion.  Solutions  of  dextrose  are  readily 
absorbed  and  lessen  the  secretion  of  hydrochloric  acid.  The  diet  of  ulcer 
has  been  previously  referred  to. 

Fats  are  quite  well  borne,  and  in  the  form  of  olive  oil  lessen  the  hydro- 
chloric acid  secretion. 

In  cases  of  subacidity  as  in  chronic  gastritis,  meat  must  be  diminished 
and  carbohydrate  material  increased.  Nutrition  must  be  improved. 
Koumiss,  matzoon,  milk,  and  raw  eggs  must  be  taken  with  crackers  and 
butter  between  meals. 

As  an  example  of  anacidity  we  have  achylia  gastrica.  This  may  be  a 
temporary  functional  disturbance  or  a  permanent  condition  with  organic 
changes.  Chemic  action  has  ceased  and  vegetable  food  (in  which  starch 
granules  possess  an  albuminous  coat)  as  well  as  animal  food  pass  from  the 
stomach  unchanged  and  irritate  the  intestines.  A  rich  carbohydrate  diet 
is  indicated,  but  it  must  be  well  pulverized. 

With  ectasia  and  gastroptosis  small  and  frequent  meals  are  indicated, 
the  character  depending  on  the  gastric  secretion.  With  severer  forms  of 
motor  insufficiency  liquids  and  mushes  are  required. 

In  nervous  dyspepsia  one  must  gradually  increase  the  quantity  of  food. 
The  administration  of  frequent  small  meals,  koumiss,  matzoon,  etc.,  be- 
tween the  chief  meals  is  of  value.     The  rest  cure  is  often  serviceable. 

One  must  individualize  in  every  patient,  and  with  the  aid  of  the  general 
principles  described  it  will  be  possible  to  formulate  a  diet  to  suit  the  case. 

Methods  of  Feeding  Before  and  After  Gastro-enterostomy. — This 
subject  is  of  such  importance  that  the  author  feels  that  he  should  offer  some 
brief  suggestions. . 

For  a  period  of  twenty-four  to  forty-eight  hours  before  gastro-enteros- 
tomy the  patient  should  be  placed  on  a  sterile  liquid  diet — broths,  bouillon, 
milk,  and  water,  all  thoroughly  sterile.  The  nares  and  pharynx  should  be 
sprayed  with  hydrogen  peroxid,  20  per  cent,  solution,  before  and  after 
each  feeding.  Acetozone,  5  grains  daily,  may  be  given  in  the  sterile 
drinking-water  in  divided  doses.  The  writer  further  advocates  in  addition 
to  the  usual  examination  of  the  urine,  that  a  special  examination  be  made 
for  acetone  and  diacetic  acid,  and  if  such  be  present,  oatmeal  gruel  (strained) 
be  given  for  several  days  previous  to  operation,  and  about  2  drams  (8.0) 
soda  bicarbonate  be  administered  daily.  Subsequent  to  operation,  3 
drams  (12.0)  soda  bicarbonate  should  be  given  daily  in  the  nutritive  ene- 
mata,  thereby  lessening  the  chance  of  vomiting  due  to  acidosis.  If  chloro- 
form is  to  be  administered,  preliminary  alkaline  treatment  is  useful  even 
if  no  acetone  be  present  before  operation.  Lavage  should  be  performed 
about  an  hour  before  operation  with  acetozone  solution  i  :  1000,  the  stom- 
ach being  thoroughly  washed  and  the  contents  well  aspirated,  so  as  to  have 
an  empty  organ.  If  this  procedure  is  not  carried  out,  particularly  if  there 
is  pyloric  stenosis,  there  may  be  considerable  fluid  in  the  stomach,  even 
though  the  patient  has  not  been  fed  for  twelve  to  eighteen  hours  previous 
to  operation.  In  view  of  the  frequency  of  colon  bacillus  infection,  the 
writer  advocates  examination  of  the  urine  for  gram  negative  bacilli  both 
before  and  after  operation.  If  they  are  in  evidence,  cultures  should  be 
taken  and  treatment  at  once  begun.     See  chapter  on  "Infections  by  the 


DIET  195 

Colon  Bacillus."  If  indicanuria  is  marked,  hexamethylenamine  tablets 
gr.  V  t.i.d.  and  lactic  acid  bacilli  in  liquid  form  should  also  be  given 
preparatory  to  operation. 

Postoperative  Feeding. — The  lips  should  be  moistened  with  wet  cloths 
after  operation  and  protocylsis  or  small  enemata  (4  ounces  normal  saline 
solution)  be  given  for  thirst.  Four  to  six  hours  after  operation  nutritive 
enemata  should  be  begun,  and  these  may  be  given  four  or  five  in  number 
during  the  twenty-four  hours  and  so  continued  for  a  week  after  operation. 
Six  hours  after  gastro-enterostomy  and  immediately  after  other  operations 
I -dram  (4.0)  doses  of  hot  water  may  be  given  by  mouth  at  first  at  hour 
intervals  and  then  increased  gradually  in  quantity.  At  the  end  of 
twenty-four  to  forty-eight  hours  i-dram  (4.0)  doses  of  strained  barley-water 
gruel  or  strained  rice  gruel  may  be  given  every  hour,  gradually  increasing 
to  larger  quantities  at  greater  intervals.  On  the  third  or  fourth  day 
peptonized  milk  in  small  quantities,  well  diluted  with  lime-water,  and  on 
the  fifth  to  seventh  days  two  to  four  raw  eggs  well  beaten  should  be  added. 
Thereafter  soft  diet  until  the  end  of  two  weeks.  Strained  gruels  the  writer 
believes  preferable  at  first  to  milk.  The  patients  upon  whom  this  operation 
is  performed  are  usually  in  poor  physical  condition  and  proper  methods  of 
early  feeding  are  indicated. 


CHAPTER  VIII 
LOCAL  TREATMENT  OF  THE  STOMACH 
LAVAGE 

Since  the  year  1867,  when  Kussmaul  employed  lavage  in  a  scientific 
manner  with  his  stomach-pump  in  the  treatment  of  disease  of  the  stomach, 
there  has  been  a  gradual  improvement  in  the  type  of  instrument.  The 
hard  tube  and  the  use  of  the  stylet  for  introduction  have  passed  into  disuse, 
and  the  modern  method  is  based  upon  the  principle  of  siphonage  with  the 
soft-rubber  tube. 

Funnel  Method. — The  one  that  is  in  most  common  use  for  washing  the 
stomach  is  by  means  of  the  funnel.  The  latter  may  be  of  hard  rubber,  glass 
or  a  flexible  rubber  funnel,  attached  to  a  piece  of  soft-rubber  tubing  about 
a  yard  long,  the  latter  being  joined  to  the  upper  end  of  the  stomach-tube 
by  a  small  connecting  glass  or  hard-rubber  tube  (Fig.  124). 


Fig.  124. — Funnel  and  tube  for  lavage. 

The  glass  funnel  is  more  readily  broken  and  the  soft-rubber  funnel  not 
as  easily  managed  by  a  novice,  so  that  for  general  use  the  hard-rubber 
funnel  is  preferable.  One  of  medium  size,  holding  about  250  c.c,  is  most 
convenient.  The  glass  connecting  tube,  in  one  case  to  my  knowledge, 
came  near  being  the  source  of  considerable  danger  to  the  patient.  During 
the  lavage  he  suddenly  grasped  the  glass  tube  and  managed  to  splinter  oflF 
a  portion  of  it,  fortunately  at  the  same  time  partially  pulling  out  the 
stomach-tube.  The  accident  was  immediately  noted  and  the  tube  entirely 
withdrawn.     Fragments  of  glass  were  found  in  the  tube.  ' 

There  is  always  the  possibility  of  a  similar  accident  to  the  glass  funnel, 
and  the  use  of  a  rubber  instrument  and  metal  or  rubber  attachment  would 
seem  to  be  preferable. 

Dangers. — There  is  one  possible  danger,  namely,  the  stomach-tube  may 
separate  from  the  attachment  to  the  funnel  tube  and  sUp  down  into  the 

196 


LOCAL  TREATMENT  OF  THE  STOMACH  I97 

Stomach.  Leube^  reports  such  a  case.  On  the  ninth  day  after  swallowing 
the  tube — after  an  attack  of  coughing — the  tube  passed  up  into  the 
esophagus  and  pharynx  and  was  withdrawn  therefrom.  The  connection 
between  the  stomach-tube  and  funnel-tube  had  become  loosened  and  the 
water  from  the  latter  forced  the  tube  into  the  mouth. 

Moreover,  every  tomach-tube  should  he  tested  before  using  to  be  sure  that 
it  is  not  cracked  or  weakened  by  some  defect. 

Friedenwald^  reports  such  an  accident  resulting  from  the  use  of  a 
defective  tube,  with  the  result  that  two  fragments  were  subsequently 
removed  by  gastrotomy. 

At  the  Manhattan  State  Hospital,  Ward's  Island,  among  our  nervous 
and  insane  patients,  a  long,  continuous,  single-piece  stomach-tube  (3H 
to  4H  feet  in  length),  with  a  rubber  funnel  at  the  end,  is  employed.  This 
obviates  all  possible  danger  of  swallowing  the  tube,  which  would  be  the 
most  likely  accident  with  this  class  of  patients. 

For  ambulance  work  such  a  tube  is  decidedly  to  be  recommended. 

Under  ordinary  conditions,  with  the  two-piece  tube,  the  patient  or  an 
assistant  can  hold  the  stomach-tube  tightly  at  the  point  of  junction  with 
the  connecting-joint,  or  the  operator  can  hold  it  firmly  at  the  lips  of  the 
patient  when  he  elevates  the  funnel. 

Selection  of  the  Stomach-tube. — The  selection  of  the  stomach-tube  may 
seem  to  be  an  unimportant  matter,  but  from  a  varied  experience  there  is 
undoubtedly  a  decided  advantage  in  the  choice  of  an  instrument. 

The  tube  should  be  of  value  both  for  aspiration  of  the  stomach-contents 
and  for  lavage.  Some  prefer  the  tube  closed  at  the  end  and  with  two 
lateral  openings,  claiming  that  there  is  less  danger  of  traumatism  from  the 
smooth  rounded  end  and  less  chance  of  aspirating  the  mucous  membrane 
into  the  openings  of  the  tube. 


i 


Fig.  125. — Best  tube  for  lavage. 

In  actual  practice,  one  has  to  exercise  more  pressure  with  this  type  of 
tube  in  order  to  force  it  to  take  the  curvature  of  the  stomach  and  lie 
parallel  with  the  same,  if  thorough  aspiration  or  lavage  is  to  be  performed. 
This  tube  is,  moreover,  not  so  readily  cleansed. 

The  tube  open  at  the  end  and  with  a  large  lateral  opening  is  preferable ; 
a  tube  with  two  lateral  openings  is  the  best,  though  not  absolutely 
essential  (Fig.  125). 

It  is  much  easier  to  thoroughly  aspirate  the  stomach  or  perform  lavage 
with  tubes  of  this  description.  The  pressure  is  so  minimized  by  these 
large  openings  that  in  my  own  experience  I  have  never  seen  damage  result 
to  the  mucous  membrane. 

For  practical  purposes  a  tube  of  from  28  to  30  (French)  is  thoroughly 
eflacient.  I  have  seen  physicians  in  their  general  practice  employ  tubes  of 
very  large  caliber,  irrespective  of  the  size  or  age  of  the  patient.    This  is 

1  Deutsch.  Arch.  f.  klin.  Med.,  vol.  xxxiii,  p.  6. 

2  American  Medicine,  August  2,  1902. 


198 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


about  as  sensible  as  using  a  large  sound  in  every  case,  irrespective  of  the 
caliber  or  conditions  of  the  urethra. 

The  tube  of  medium  cahber  that  I  have  indicated  will  pass  comfortably 
through  any  average  or  even  small  adult  esophagus,  unless  stricture  be 
present.  The  best  tubes  are  marked  at  about  18  inches  from  the  distal  end 
(it  is  16  inches  from  the  teeth  to  the  stomach),  and  by  this  means  we  know 
when  the  instrument  has  reached  that  organ.  The  tube  should  be  inserted 
a  little  further  until  checked  by  the  lower  border  of  the  stomach,  and  then 
withdrawn  slightly  until  no  resistance  is  felt  by  the  operator.     With 


Fig.   126. — Correct  method  of  passing  the  stomach-tube. 

ectasia  or  gastroptosis  it  may  be  necessary  to  pass  it  a  considerable 
distance. 

If  the  tube  is  not  marked  it  is  easy  to  estimate  the  correct  distance 
and  make  a  scratch-mark  on  the  tube  with  a  pencil,  or  insert  it  until 
checked  by  the  lower  border  of  stomach,  as  just  described. 

A  pitcher',  pail,  or  large  basin,  towels,  and  rubber  sheets  are  required. 
Special  irrigating  stands  can  be  secured,  but  are  unnecessary  and  expensive 
tor  the  young  physician. 

The  correct  method  of  lavage  in  ofl&ce  practice,  without  an  assistant,  is 
first  described.     False  teeth  should  he  removed. 

The  patient  should  sit  upright  in  a  straight  back  chair,  with  a  rubber 


LOCAL  TREATMENT  OF  THE  STOMACH 


199 


sheet  or  towels  about  the  neck  thus  protecting  the  front  of  the  body.  His 
confidence  should  be  gained.  He  should  be  told  that  the  procedure  is 
slightly  disagreeable,  but  absolutely  safe.  He  should  be  admonished  that 
he  is  to  breathe  deeply  and  steadily  all  the  time,  as  this  will  prevent  the 
gagging  and  sensation  of  choking;  and  he  should  be  directed,  while  the 
lavage  is  actually  in  process,  to  follow  out  this  method. 

The  stomach-tube  should  bQ  lubricated  by  dipping  it  in  warm  water. 
Vaselin,  cold  cream,  or  olive  oil  may  be  used,  but  they  are  disagreeable  and 
unnecessary.  The  irrigating  fluid  should  be  pleasantly  warm  to  the  hand. 
This  is  sufficient  index  to  the  temperature,  though  for  absolute  accuracy  a 
thermometer  may  be  employed;  and 
about  100°  to  ioi°F.  is  correct. 

Plain  water  or,  preferably,  normal 
saline  solution,  i  dram  (4.0)  of  salt  to 
I  pint  (500  c.c.)  of  water,  is  employed 
in  the  average  case  for  the  purpose  of 
cleansing  the  stomach.  Special  solu- 
tions will  be  appropriately  indicated 
in  their  places. 

The  patient  should  bend  the  head 
slightly  forward  and  open  the  mouth, 
but  not  protrude  the  tongue. 

In  rare  cases  a  2  per  cent,  cocain 
or  5  per  cent,  eucain  spray  may  be 
required  if  the  pharynx  is  irritable. 
Freezing  the  stomach-tube  is  also 
serviceable.  This  consists  in  placing 
the  tube  for  a  brief  period  in  ice  or 
ice-cold  water,  so  that  it  is  extremely 
cold  when  it  enters  the  pharynx,  hav- 
ing an  anesthetic  effect. 

The  physician  should  never  insert 
his  finger  into  the  mouth  to  depress 
the  tongue  or  act  as  a  guide  to  the  tube,  as  it  renders  the  operation  more 
difficult,  and  will  only  cause  gagging  or  vomiting. 

Most  of  our  text-books  advise  that  the  operator  stand  in  front  of  the 
patient  and  pass  the  tube  along  the  base  of  the  tongue. 

The  most  practical  method  is  the  one  shown  in  Fig.  126. 

The  physician  stands  on  the  right  side  and  a  little  back  of  the  patient 
and  passes  the  left  arm  about  the  neck,  the  fingers  supporting  the  tube  at  the 
lips,  the  little  finger  resting  on  the  chin. 

This  method  prevents  the  patient  from  throwing  his  head  back  and 
struggling,  and  gives  the  operator  perfect  control. 

The  stomach-tube  should  be  passed  into  the  mouth  with  the  right 
hand,  it  being  held  about  2  inches  from  the  lips,  and  being  supported  by 
the  left  hand  against  the  roof  of  the  mouth.  It  should  then  be  rapidly 
forced  in  with  the  right  hand,  the  index-finger  and  thumb  of  the  left  hand 
continuously  aiding  its  introduction. 

The  tube  follows  the  arch  of  the  mouth,  and  glides  down  the  posterior' 


Fig.  127. — Course  of  tube. 


200 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


wall  of  the  pharynx  (Fig.  127).  Interference  from  the  tongue  is  thus 
avoided. 

When  its  progress  is  checked,  the  patient  should  be  told  to  swallow, 
and  it  will  enter  the  esophagus.  It  should  now  be  rapidly  fed  into  the 
mouth  until  the  marked  ring  has  been  reached,  and  then  more  slowly  to  the 
bottom  of  the  stomach. 

If  the  tube  is  checked  during  introduction,  it  is  probably  due  to  a 
spasm  of  the  esophagus,  and  the  act  of  swallowing  or  a  deep  inspiration  will 
free  it.     There  is  practiaUy  no  danger  of  its  entrance  into  the  larynx. 


Fig.  128. — ^Lavage  by  single  operator:  Position  one. 

Sometimes  the  patient  may  become  cyanotic,  and  a  beginner  may  fear 
that  this  has  happened;  but  this  is  due  to  the  fact  that  the  breath  is  held, 
and  deep  and  regular  breathing  will  immediately  relieve  the  condition. 

Occasionally  the  tube  may  slip  out  of  the  esophagus  and  coil  in  the 
mouth,  but  that  is  easily  detected.  Patients  accustomed  to  lavage  can 
often  introduce  the  tube  themselves. 

I  prefer  a  funneP  of  a  capacity  of  250  c.c.  or  about  8  ounces,  and  allow 

*  If  the  funnel  is  of  smaller  capacity,  more  funnelfuls  should  be  used;  total  250  to 
500  c.c.  (8  ounces  to  i  pint). 


LOCAL  TREATMENT  OF  THE  STOMACH 


20I 


two  funnelfuls  to  run  into  the  stomach  (in  all  about  i  pint)  and  to  run  out 
again  at  once.  It  is  a  bad  practice  to  overdistend  the  stomach,  just  as  it 
is  the  bladder.     At  times  I  employ  one  funnelful. 

Lavage  is  continued  until  the  water  is  perfectly  clear.  The  patient 
may  move  the  body  about  so  as  to  bring  the  water  in  more  thorough 
contact  with  the  stomach  wall,  or  may  lie  down,  as  suggested  by  Fleiner, 
rotating  to  the  right  side  and  then  to  the  left;  but  this  is  rarely  necessary 
except  in  cases  of  marked  dilatation  with  insufficiency. 


Fig.  129. — ^Lavage  by  single  operator:  Position  two. 

Lavage  by  a  Single  Operator. — During  lavage  the  patient  steadies 
the  stomach-tube,  holding  it  to  the  lips  with  one  hand.  He  should  be 
instructed  not  to  bite  the  tube. 

The  operator  holds  the  funnel  in  the  left  hand  and  pours  the  water  into 
it  from  a  pitcher  in  the  right  hand,  then  elevates  the  funnel  to  about  the 
level  of  the  patient's  forehead  (Fig.  128). 

As  soon  as  it  is  empty,  he  pours  in  the  second  funnelful.  Then  before 
the  latter  is  empty  he  quickly  lowers  it  to  below  the  level  of  the  patient's 
stomach,  and  allows  the  fluid  to  siphon  out  into  a  pail  or  bowl  placed  on  the 
floor  to  the  right  of  the  patient  (Fig.  129). 

The  rim  of  the  funnel  should  be  held  upward.  It  should  be  allowed  to 
fill  before  emptying  it,  as  in  this  way  it  can  be  estimated  whether  the 


202 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


amount  of  fluid  that  flows  out  equals  that  which  was  poured  in.  In  empty- 
ing the  funnel  it  should  only  be  slightly  tipped,  so  that  the  column  of  water 
is  still  visible  in  the  bottom.  This  prevents  the  entrance  of  air  and  also 
the  aspiration  of  the  mucous  membrane  into  the  openings  of  the  tube. 

When  the  washing  is  completed,  the  funnel  should  be  rapidly  raised  and 
the  stomach-tube  withdrawn  in  this  position.  The  small  column  of 
water  remaining  in  the  tube  flows  back  into  the  stomach  and  prevents  the 


Fig.   130. — ^Lavage  by  two  nurses:  Step  one. 

possibility  of  the  accident  just  noted.  The  tube  should  not  be  pinched 
during  the  withdrawal,  as  mucous  membrane  might  be  aspirated  in. 

If  the  water  stops  flowing  during  lavage,  one  should  observe  if  the 
patient  has  not  inadvertently  withdrawn  the  tube  slightly,  and  in  this 
event,  it  should  be  pushed  back. 

On  the  other  hand,  the  tube  may  be  bent  and  the  flow  stopped  by 
reason  of  its  being  forced  too  far  into  the  stomach.  If  so,  withdrawing 
it  slightly  will  correct  the  trouble. 

Pieces  of  food  may  occlude  the  tube  by  stopping  up  the  stomach 


LOCAL  TREATMENT  OF  THE  STOMACH 


203 


openings.  By  pouring  more  water  into  the  funnel  the  instrument  will 
usually  be  cleared  out.  By  forcing  air  through  the  stomach-tube  or  by 
suction  this  can  be  accomplished  if  the  above  method  fails.  Thus,  a  rub- 
ber bulb  with  metal  attachments  is  inserted  between  the  stomach-tube 
and  the  funnel-tube,  in  place  of  the  tube  joining  them.  Close  the  end 
leading  to  the  funnel  and  compress  the  bulb.  This  will  force  air  through 
the  stomach-tube;  or  first  compress  the  bulb,  then  close  the  distal  end  con- 
necting with  the  funnel  by  making  an  angle  or  compressing  the  soft  tube 
of  the  latter,  then  let  the  rubber  bulb  expand  again.     The  last  method 


Fig.   131. — ^Lavage  by  two  nurses:  Step  two. 

described  is  that  originated  by  Friedlieb.  The  stiff  rubber  bulb  made  by 
Tiemann,  with  metal  attachments,  is  a  better  instrument  than  Friedlieb 's, 
which  has  glass  attachments. 

On  rare  occasions  it  may  be  necessary  to  remove  the  tube,  clean  it,  and 
reintroduce  it. 

In  emergency  in  country  practice  one  can  employ  an  ordinary  tin 
kitchen  funnel  and  a  piece  of  small  red  or  even  white  rubber  tubing.  A 
fountain  syringe  with  the  long  soft-rubber  tubing  has  been  used  in  poison 
cases.     A  stomach-tube  can  be  improvised  out  of  a  long  colon  tube. 


204  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

The  lateral  opening  can  be  cut  with  a  pair  of  sharp  scissors,  and  the  rough 
edges  of  the  window  burned  over  an  alcohol  lamp,  wiping  them  quickly 
with  a  wet  cloth,  thus  making  a  smooth  velvet  eye.  If  the  opening  of  the 
improvised  tube  is  rough,  it  can  be  trimmed  down  and  smoothed  by  the 
above  method. 

It  is  best  to  lubricate  all  such  emergency  tubes  with  olive  oil  or  vaselin, 
as  they  are  less  smooth  and  more  difl&cult  of  introduction. 

With  an  intelligent  patient  who  will  cooperate  with  the  physician  the 
method  described  is  excellent.  .  In  nervous  cases,  when  possible,  it  is 
easier  to  have  an  assistant  or  for  two  nurses  to  perform  lavage,  as  in  Figs. 
130  and  131. 

The  technic  is  the  same  as  to  passage  of  the  tube,  etc.  One  nurse 
steadies  the  tube  at  the  patient's  mouth  and  carries  on  the  manipulation 
with  the  funnel,  the  other  pouring  the  fluid. 


Fig.  132. — Friedlieb's  apparatus  for  lavage. 

If  the  patient  resist,  nurse  No.  i  both  holds  the  tube  and  prevents 
interference  by  the  patient's  hands,  while  nurse  No.  2  manages  the 
funnel  and  pours  the  fluid.  Friedlieb's  apparatus  is  demonstrated  in 
Fig.  132. 

In  Figs.  133  and  134  we  have  two  nurses  performing  lavage  with  a 
funnel,  the  modified  Friedlieb  bulb  connecting  the  stomach-tube  and  funnel- 
tube.    This  is  a  favorite  method  of  mine. 

It  is  best  to  close  the  bulb  on  the  side  joining  the  stomach-tube  by 
pinching  the  latter  with  the  fingers,  then  squeeze  out  the  air  and  pour  the 
fluid  into  the  funnel,  allowing  the  bulb  to  fill  with  water.  This  prevents 
aspirating  air  into  the  stomach.  Lavage  is  then  performed  in  the  usual 
way.  The  advantage  is  that  we  have  the  bulb  in  position  to  employ  air- 
pressure  or  suction  if  the  stomach-tube  becomes  occluded.  Intermittent 
squeezing  of  the  bulb  also  aids  expulsion  of  the  fluid. 


LOCAL   TREATMENT   OF   THE    STOMACH 


205 


The  modified  bulb  made  by  Tiemann  has  metal  connections  (instead 
of  glass)  and  is  stiffer  and  better  than  Friedlieb's. 

Irrigation  of  the  Stomach  by  Means  of  a  Glass  Y  or  T. — This  method 
has  generally  been  known  as  Leube-Rosenthal's,  but  R.  H.  M.  Dawbarn 
has  taught  this  plan  for  many  years.     It  is  useful  for  office  work. 

A  large  glass  irrigator,  about  2  quarts'  capacity,  is  hung  at  a  level 
slightly  above  the  patient's  head.  This  should  be  marked  in  250  to  2000 
CO.  or  in  ounces  or  pints.     This  irrigator  is  connected  with  a  long  soft- 


^j 


Fig.  133. — Nurses  performing  lavage  with  modified  Friedlieb  bulb:  Step  one. 

rubber  tube  by  means  of  a  Y-  or  T-shaped  glass  or,  preferably,  hard-rubber 
or  metal  tube;  one  branch  with  the  stomach-tube  and  the  other  with  a 
carry-off  tube  which  passes  down  into  a  pail  or  basin. 

The  irrigator  tube  should  be  closed  with  a  clamp.  This  is  kept  closed 
until  after  the  introduction  of  the  stomach-tube  and  commencement  of 
lavage.  A  second  clamp  on  the  outflow  tube  is  unnecessary,  as  all 
manipulation  can  be  thereafter  conducted  by  the  operator,  by  alternately 
opening  and  closing  the  inflow  and  outflow  tubes  with  the  fingers. 

The  stomach-tube  is  introduced  in  the  way  described.     The  outflow 


2o6 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


is  pinched  as  in  Fig.  135,  and  the  clamp  on  the  inflow  tube  opened.  Only 
500  c.c.  of  fluid  or  about  i  pint,  is  allowed  to  flow  into  the  stomach.  I  do 
not  approve  of  employing  the  larger  quantities,  as  recommended  by  some 

authors. 

While  the  fluid  is  still  entering,  the  outflow  tube  is  suddenly  released 
and  part  of  the  current  is  diverted,  thus  starting  the  siphon  action.  The 
inflow  tube  is  then  pinched,  as  in  Fig.  136,  and  the  stomach  rapidly  empties 
itself.  The  outflow  is  then  pinched  and  the  inflow  released,  and  so  on.  The 
patient  may  shake  his  abdomen,  so  as  to  wash  all  parts  more  thoroughly. 


Fig.    134. — Xurses  performing  lavage  with  modified  Friedlieb  bulb:  Step  two. 


This  procedure  must  be  continued  until  the  wash-water  returns  clear. 

There  are  cases  among  the  insane  or  when  the  patient  is  unconscious 
when  the  methods  described  cannot  be  used. 

It  may  be  necessary  to  employ  a  mouth-gag,  forcibly  distend  the  jaws, 
and  force  in  the  stomach-tube.  Under  such  conditions  numerous  assist- 
ants may  be  required. 

The  operation  may  be  performed  with  the  patient  lying  on  the  back, 
being  properly  restrained.  The  tube  should  be  passed  along  the  roof  of  the 
mouth,  and  the  patient  should  lie  on  a  sufficiently  high  level,  so  that  the 


LOCAL  TREATMENT  OF  THE  STOMACH 


207 


funnel  can  be  carried  below  the  level  of  the  body  in  order  to  secure  the 
siphon  effect. 

If  no  mouth-gag  can  be  secured,  the  handle  of  a  spoon,  protected  with 
gauze  or  a  handkerchief,  can  be  inserted  between  the  teeth,  turned,  and 
the  jaws  forced  apart,  or  some  such  instrument  improvised. 

The  director  devised  by  Mark  Knapp  (Fig.  137)  would  be  of  value  in 
such  cases.  Being  all  metal,  it  can.be  left  in  situ  during  lavage,  and  acts 
as  a  gag. 


Fig.  135. — Stomach  irrigation  by  the  T-method :  First  step. 


The  simplest  method  in  such  cases  is  to  introduce  the  tube  through  the 
nostril. 

The  technic  of  lavage  by  this  method  is  shown  in  Figs.  138  and  139. 

The  tube  is  passed  along  the  floor  of  the  nostril,  just  as  is  the  guide  for 
posterior  nasal  tamponade.  It  is  fed  directly  through  the  nostril  for  about 
20  inches,  and  no  difficulty,  as  a  rule,  is  experienced,  as  it  passes  down  the 
posterior  wall  of  the  pharynx  and  so  on  into  the  esophagus  and  stomach. 

The  nares  should  be  examined,  and  that  nostril  selected  which  is  of 


208 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


larger  dimensions.     This  is  important,  as  there  are  -frequently  deflections 
of  the  septum. 

At  the  Manhattan  State  Hospital  a  stomach-tube  of  fair  size  (about  27, 
French)  is  employed.     I  frequently  use  this  tube  in  my  office  lavage  per 
It  is  rarely  necessary  to  employ  the  very  small  tubes  so  frequently 


orem. 


recommended.     For  thorough  lavage  a  fair  caliber  is  preferable. 

Gavage. — Gavage  is  a  different  proposition  and  the  small  tubes  are 
to  be  preferred. 

Gavage  or  forced  feeding  is  employed  chiefly  among  the  insane  who 


Fig.  136. — T-method:  Second  step. 


refuse  food,  the  tube  being  introduced  as  in  lavage,  the  nasal  route  being 
preferable.  It  may  be  necessary  to  employ  this  method  of  feeding  in 
children  who  have  been  intubated  and  also  in  feeding  the  unconscious. 
In  some  cases,  of  course,  the  mouth  route  niay  be  preferable. 

Hemmeter  and  others  have  employed  double-current  tubes  for  lavage, 
but  I  can  see  no  advantage. 

Indications  for  Lavage. — i.  In  All  Cases  oj  Poisoning. — Some  authors 
advise  against  it  in  cases  from  acids  or  alkalis,  for  fear  of  causing  perfora- 
tion; but  there  is  greater  danger  of  the  latter  by  leaving  the  poison,  since 


LOCAL  TREATMENT  OF  THE  STOMACH  209 

thorough  emesis  cannot  be  secured,  especially  if  the  patient  be  uncon- 
scious; there  is  the  increased  danger  of  subsequent  damage  to  the  intestinal 
canal  below  and  often  to  the  other  organs,  such  as  the  liver  and  kidneys,  or 
cardiac  or  respiratory  poisoning  might  result. 

2.  In  acute  and  uncontrollable  vomiting  from  any  cause,  as  from  acute 
gastritis,  the  value  of  lavage  was  first  definitely  shown  by  our  specialists  in 
pediatrics.     Bilious  vomiting  is  included. 

3.  In  chronic  gastritis,  with  excessive  production  of  mucus. 

4.  In  dilatation  of  the  stomach  (atonic  type),  where  there  are  marked 
fermentation  and  motor  insufficiency. 

5.  In  dilatation  of  the  stomach  (stenotic  type),  with  fermentation,  motor 
insufficiency,  gastritis,  vomiting,  etc. 

6.  In  acute  dilatation  of  the  stomach  from  all  causes. 


Fig.  i37.^Knapp's  director. 

7.  In  vomiting  due  to  vicious  circle,  after  gastro-enterostomy. 

8.  At  the  end  of  anesthesia,  to  prevent  postoperative  vomiting,  or  to 
treat  the  same,  if  it  has  occurred,  before  anesthesia  and  also  to  prepare 
for  gastro-enterostomy  so  as  to  have  a  clean  stomach  for  the  surgeon. 

9.  In  postoperative  intestinal  paresis  (correctly,  gastro-intestinal 
paresis)  lavage  should  be  employed  together  with  enteroclysis. 

10.  In  acute  tympanitis  of  typhoid  fever,  lavage  is  of  great  value  to  aid 
reduction  of  the  same;  especially  when  hemorrhage  is  occurring  and 
enteroclysis  is  contraindicated,  see  Typhoid  Fever. 

11.  In  intestinal  obstruction,  especially  in  intussusception.  Frequent 
lavage  has  so  relieved  abdominal  distention  above  the  point  of  obstruction 
that  the  condition  has  been  spontaneously  reduced.  It  also  checks  the 
vomiting  in  this  condition. 

12.  Occasionally  lavage  with  iced   water  has  proved  successful  in 
14 


2IO 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


uncontrollable  hemorrhage  from  gastric  ulcer.     It  should  be  used  as  a  last 
resort  and  with  great  caution. 


Fig.  138. — ^Lavage  through  the  nostril:  First  step. 


Fig.  139. — ^Lavage  through  the  nostril:  Second  step. 

13.  It  is  also  of  service  in  esttmatmg  the  degree  oj  motor  insufficiency  b}" 
washing  out  the  residue  after  aspiration  following  the  test-meal. 

14.  In  gastric  tetany. 

15.  In  the  convulsions  of  young  chtldren  which  immediately  follow 


LOCAL  TREATMENT  OF  THE  STOMACH  211 

the  ingestion  of  improper  food.     Epileptiform  convulsions  occasionally 
occur  in  adults  from  overfeeding  and  lavage  is  indicated. 

i6.  In  vomiting  of  peritonitis. 

Contraindications  to  Lavage. — i.  Aneurysm  of  the  aorta. 

2.  Gastric  hemorrhage,  as  a  general  rule,  except  as  in  No.  12  above. 

3.  Marked  heart  lesions,  when  danger  might  be  incurred,  such  as  in 
angina,  etc. 

4.  Last  months  of  pregnancy. 

5.  Special  conditions  where  it  might  damage  the  patient  or  be 
dangerous. 

In  cases  of  poisoning  lavage  would  take  precedence  over  all  other  risks. 

6.  Recent  rectal,  vesical,  or  renal  hemorrhage. 

7.  Recent  hemoptysis. 

8.  Extreme  prostration  from  any  cause. 

9.  High  arterial  tension  with  respiratory  disturbance. 

Stomach  Douche. — This  method  was  first  described  by  Malbranc, 
and  the  measure  was  first  employed  by  Kussmaul.  It  consists  in  sprink- 
ling the  stomach  with  water  under  pressure.  Ewald  and  Rosenheim^  have 
devised  the  most  practical  stomach-tubes  for  this  purpose. 


Fig.  140. — Tube  for  stomach  douche. 

The  instrument,  as  in  Fig.  140,  has  numerous  small  lateral  openings 
and  a  slightly  larger  hole  at  the  end.  This  last  is  so  that  the  water  can 
run  off  more  rapidly  in  emptying  the  stomach,  and  any  mucus  or  food 
products  can  more  readily  escape.  If  the  hole  is  too  large,  the  bulk  of  the 
fluid  will  pass  through  this  and  no  diffuse  irrigation  of  the  mucous  mem- 
brane be  accomplished.  Some  tubes  have  only  a  number  of  small  holes 
at  the  end. 

The  tube  is  introduced  in  the  manner  already  described,  and  the 
funnel  method  is  employed.  This  is  held  quite  high  above  the  patient, 
so  that  the  water  is  under  considerable  pressure  and  numerous  small 
streams  are  forced  out  of  the  tube.  . 

Rosenheim  recommends  it  on  an  empty  stomach  before  breakfast,  or, 
if  this  is  impractical,  three  or  four  hours  after  the  first  meal.  It  is  ap- 
plicable to  mild  motor  insufficiency.  He^  advises  its  use  in  mild  cases  of 
chronic  catarrh  and  in  irritation  of  the  sensory  and  secretory  apparatus. 

Salt  added  to  the  irrigation  fluid  increases  the  hydrochloric  acid  pro- 
duction, nitrate  of  silver  (in  i  :  1000  strength)  or  argyrol  or  protargol 
Hooo  reduce  the  secretion  of  gastric  juice.     Other  observers  have  agreed 

^  Therapeut.  Monatssch.,  August,  1892. 
*  Berlin.  Klinik,  1894,  No.  71. 


212 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


with  these  findings,  and  Riegel  advocates  the  use  of  the  silver  nitrate. 
Fleiner^  recommends  the  douche  for  stimulating  the  appetite.  Thus, 
infusions  of  hops,  quassia,  condurango,  or  cinchona  bark  are  valuable. 

Boric  acid,  salicylic  acid,  sodium  salicylate,  thymol,  gomenol,  creolin, 
lysol,  etc.,  may  be  empolyed  in  average  strength  (i  :  looo)  if  antiseptic 
treatment  is  indicated. 

If  medicated  douches  are  employed,  the  stomach  should  first  be  washed 
with  plain  water;  then  the  medicated  fluid  applied  for  one  to  three  minutes 
and  then  siphoned  out;  the  stomach  should  be  rewashed  with  plain  water 
if  toxic  materials  have  been  used. 

Gross  has  devised  a  double-current  gastric  douche,  which  is  scarcely 
practical,  and  Einhorn  an  instrument  with  a  ball-valve  and  hard-rubber 
tip. 

The  following  simple  addition  to  the  Ewald-Rosenheim  tube  gives 


»ui. 


Fig.  141. — The  bulb- 
compression  method  of 
spraying  the  stomach. 


Fig.     142. — The    Y-method    of    spraying    the 
stomach. 


satisfactory  results.     Employ  a  fountain  syringe  instead  of  a  funnel  and 
also  a  compression  bulb  (Fig.  141). 

The  stomach  douche  is  passed  in  the  usual  way,  and  the  bulb  (aspirat- 
ing) joins  it  to  the  fountain  syringe,  which  contains  the  irrigating  fluid  at  a 
temperature  of  ioo°F.  Clip  X  is  previously  closed.  The  tube  is  pinched 
tightly  at  A ,  and  the  clip  then  opened.  By  squeezing  the  bulb  B,  all  air  is 
driven  out  through  the  fountain  syringe  C.  The  bulb  is  then  released 
and  fills  with  fluid.  This  prevents  air  from  entering  the  stomach.  The 
finger  releases  the  tube  at  A  and  the  fluid  begins  to  flow  into  the  stomach; 
and  by  intermittent  pressure  of  bulb  (B)  the  spraying  effect  can  be 
intensified  at  the  will  of  the  operator.  When  the  douching  is  completed, 
the  bulb  is  detached  from  the  fountain  syringe  and  with  pressure  of  the 

^  Saraml.  klin.  Vortrage,  New  Series,  No.  103. 


LOCAL  TREATMENT  OF  THE  STOMACH 


213 


same — the  thumb  over  the  end — slight  aspiration  is  commenced  and  the 
contents  will  then  siphon  out. 

In  Fig.  142  is  illustrated  the  Y-method  of  spraying  the  stomach.  The 
technic  is  the  same  as  the  similar  procedure  in  lavage. 

In  Fig.  143  the  use  of  the  alternate  hot  and  cold  douche,  with  the  pres- 
sure bulb,  is  depicted. 

The  addition  of  the  bulb  enables  one  to  employ  the  spray  without 
distending  the  stomach  with  air,  and  to  reach  much  further  than  with 
simple  hydrostatic  pressure.     When  stronger  medicaments  are  employed, 


CkiP 


auLB 


BUCKLT 

Fig.   143. — The  alternate  douche. 

the  rapid  emptying  of  the  stomach  within  one  to  two  minutes  and  im- 
mediate lavage  eliminate  all  danger,  especially  in  view  of  the  fact  that  by 
the  compression  method  of  spraying  much  less  fluid  is  required,  as  com- 
pared with  the  older  procedures. 

The  temperature  of  the  fluid  should  be  about  ioo°F.  When  stimulat- 
ing effects  are  required,  it  could  be  105°  to  ii5°F.  if  cold,  at  75°  to  8o°F. 
when  used  with  the  alternate  douche. 

In  atony,  with  or  without  commencing  dilatation,  the  douche  method, 
employing  in  all  not  over  yi  pint  to  i>2  pints,  is  at  times  of  service  to 
stimulate  the  organ.     With  this  exception,  I  rarely  use  it. 


214  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

Gastric  Spray. — This  consists  of  an  ordinary  spray  apparatus  with  a 
double  bulb,  to  which  is  attached  a  soft  Nekton  tube  70  cm.  long;  within 
this  is  a  fine  central  flexible  tube^  which  connects  the  inner  capillary  tube 
with  the  nozzle  (Fig.  144). 

Einhorn,'  who  devised  the  tube,  recommends  it  highly,  as  thereby  one 
employs  a  small  amount  of  fluid  to  secure  results;  and  hence  there  is  less 
danger  when  toxic  or  irritating  substances  are  used. 

The  spray  should  be  employed  when  the  patient  has  fasted  or  after  a 
previous  lavage.  The  bottle  is  filled  with  the  required  amount  of  the 
antiseptic  solution,  the  tube  dipped  in  warm  water,  and  introduced  in  the 
usual  manner. 

The  patient  should  hold  the  tube  at  the  lips  and  the  operator  steady 
the  bottle  and  compress  the  bulb.  The  spraying  should  be  begun  when  the 
tube  has  entered  to  the  mark  (about  16  inches).  It  can  be  forced  further 
in. 

Einhorn  advocates  it  to  disinfect  the  mucous  membrane  of  the  stomach; 


144. — Einhorn's  gastric  spray. 


for  the  application  of  astringents;  and  to  relieve  pain  in  gastralgia,  as  from 
ulcer,  cicatrix,  or  cancer. 

It  is  recommended  in  erosions  of  the  stomach;  in  chronic  gastritis,  with 
marked  production  of  mucus;  in  hypersecretion  and  hyperacidity,  and  in 
gastralgia. 

Riegel  holds  that  the  necessary  insufflation  of  air  distends  the  stomach, 
and  on  this  account  it  is  objectionable.  I  have  found  the  weak  spray, 
1 :  5000  nitrate  of  silver  or  argyrol  or  protargol  i  :  2500,  of  value  in  gastralgia 
and  in  the  treatment  of  erosions. 

STOMACH  POWDER-BLOWER 

A  dry  method  for  spraying  the  stomach  with  insoluble  substances 
(powders)  has  been  devised  by  Einhorn.^  His  instrument  consists  of  a 
flexible  rubber  tube  about  28  inches  long  (Fig.  145),  the  distal  end  of  which 
connects  with  an  air  suction-bulb. 

1  New  York  Medical  Journal,  Sept.  17,  1892. 

2  New  York  Medical  Journal,  April  i,  1899. 


LOCAL  TREATMENT  OF  THE  STOMACH 


21  = 


Fig.  145 — I,  The  stomach  powder-blower:  a,  the  tubing  part;  &,  connection  with 
the  bulb;  c,  hard-rubber  end  with  screw  thread  for  capsule;  2,  the  capsule-shaped 
powder  receptacles  (natural  size);  3,  the  small  spoon  for  putting  the  powder  into  the 
capsule. 


i^: 


Fig.  146. — New  model  powder-blower. 


2l6  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

The  extremity  of  the  tube  is  attached  to  a  hard-rubber  piece  c,  which 
is  hollow  and  has  lateral  openings.  It  is  provided  with  a  screw  thread. 
To  this  is  attached  a  capsule  with  numerous  side  holes.  Capsules  of 
several  sizes  are  furnished.  A  capsule  is  filled  with  powder  and  screwed 
on  to  the  tip  piece.     A  small  spoon  is  employed  to  fill  the  capsule. 

It  is  well  to  lubricate  the  latter  with  a  thin  layer  of  vaselin  to  prevent 
entrance  of  moisture.  The  tube  is  then  dropped  into  warm  water  and 
inserted  into  the  stomach  in  the  usual  manner.  The  bulb  is  quickly 
compressed  several  times  and  the  air  drives  out  the  powder,  opening  up 
the  vaselin  layer  over  the  holes. 

It  has  been  recommended  for  ulcer  of  the  stomach,  employing  bismuth 
subnitrate;  in  gastralgia,  orthoform;  and  in  erosions,  protargol  or  supra- 
renal powder. 

I  would  not  care  to  advocate  the  passage  of  the  instrument  in  ulcer, 
but  in  tTie  other  conditions  it  is  at  times  of  service.  Recently  Einhorn 
has  modified  this  instrument  (Fig.  146).  There  is  a  double  bulb  with  a. 
stop-cock.  This  is  last  closed.  Bulb  a  is  compressed  several  times, 
thus  overdistending  bulb  h,  which  is  without  valves.  The  stop-cock  is 
opened  and  a  single  blast  of  air  distributes  the  powder:  about  15  gr.  (i.o) 
is  the  capacity  of  the  capsule. 

ELECTRICITY 

From  clinical  experience  it  is  found  that  the  electric  current  exercises 
an  influence  on  the  secretory  and  motor  functions  of  the  stomach  and  also 
on  its  sensibility.  Physiologic  experiments  and  clinical  experience  do  not 
always  agree. 

Meltzer,  experimenting  on  animals,  passed  strong  induced  currents 
through  the  fundus  of  the  organ  and  noted  no  contraction  of  the  pylorus. 
The  influence  of  the  anesthetic  or  of  morphin  or  similar  drugs  would  in- 
fluence the  experiment. 

Pepper  demonstrated  on  a  very  thin  patient  that  percutaneous 
electricity  produced  no  peristaltic  movements  in  the  stomach.  It  is 
believed  that  it  is  through  contraction  of  the  abdominal  muscles  that 
this  procedure  influences  the  musculature  of  the  stomach.  The  two 
methods  for  the  application  of  the  galvanic  and  faradic  current  are  the 
percutaneous  and  the  intraventricular.  The  latter  seems  preferable  from  a 
therapeutic  standpoint,  but  the  former  is  easier  and  is  more  readily  sub- 
mitted to  by  the  patient. 

Percutaneous  Method. — Von  Ziemssen  employs  two  large  plate- 
electrodes,  one  anteriorly  between  the  pylorus  and  fundus,  and  the  other 
from  the  fundus  to  spinal  column,  with  a  separating  space  of  only  2  cm. 
The  electrodes  should  be  moistened,  and  sufficient  current  employed  to 
cause  strong  contraction  of  the' abdominal  muscles.  If  smaller  sponges 
are  used,  they  can  be  moved  about  in  these  regions.  The  seance  should 
last  ten  to  fifteen  minutes,  and  be  carried  out  at  first  every  other  day, 
depending  upon  indications,  which  are  the  same  as  for  the  intragastric 
method. 

Intragastric  Method. — Kussmaul  first  suggested  the  internal  applica- 
tion of  electricity,  and  was  the  first  to  introduce  the  sound  with  a  copper 


LOCAL  TREATMENT  OF  THE  STOMACH 


217 


wire  and  olive  point  into  the  stomach.  Bardet  improved  upon  this,  and 
employed  an  electrode  which  did  not  touch  the  stomach  wall,  the  circuit 
being  established  by  filling  the  organ  with  water. 

Numerous  intragastric  electrodes  have  been  devised,  of  which  the 
most  practical  are  Einhorn's,  Lockwood's,  and  Bassler's. 

Lockwood's  Electrode. — This  consists  of  a  very  small  cable  of  con- 
ducting wire  covered  with  rubber.     The  intragastric  tip  is  olive  pointed 


Fig.  147. — Lockwood's  intragastric  electrode. 

and  protected  from  the  gastric  mucous  membrane  by  a  rubber  fenestrated 
capsule  (Fig.  147).  The  instrument  in  appearance  is  much  like  his  gastro- 
diaphane.  It  is  easy  of  introduction  and  of  such  small  caliber  that  it 
does  not  incommode  the  patient.  A  glass  or  two  of  water  is  administered 
on  the  empty  stomach,  and  the  instrument  is  passed  along  the  roof  of 
the  mouth,  like  the  stomach-tube,  about  18  inches  or,  preferably,  until 
the  resistance  of  the  stomach  wall  is  encountered.  It  is  then  slightly 
withdrawn.     The  outer  end  of  the  instrument  is  furnished  with  a  key 


Fig.  148. — The  deglutible  stomach  electrode. 

which  is  inserted  into  the  negative  pole  of  the  battery.  The  sponge  which 
is  connected  to  tne  positive  pole  is  applied  over  the  stomach. 

Einhorn's  Deglutible  Electrode. — The  intragastric  tip  is  similar  in 
construction  to  Lockwood's.  The  conducting  wire  is  much  more  flexible 
than  Lockwood's  and  is  covered  with  thin  rubber.  It  is  not  introduced 
by  the  operator,  but  swallowed  by  the  patient,  being  similar  in  principle 
to  the  stomach  bucket  (Fig.  148). 

The  key  is  connected  to  the  cord  of  the  negative  pole  of  the  battery. 


2l8  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

The  patient  drinks  about  a  glass  of  water.  The  deglutible  electrode  is 
placed  on  the  root  of  the  tongue,  and  the  patient  is  directed  to  swallow 
more  water,  which  carries  the  instrument  into  the  stomach.  A  mark 
can  be  placed  on  the  cord,  about  20  inches  from  the  electrode,  to  determine 
that  it  has  reached  the  bottom  of  the  stomach.  The  sponge  is  attached 
to  the  positive  pole.  If  there  is  resistance  to  the  withdrawal  of  the 
instrument,  the  patient  should  swallow  to  relieve  the  spasm. 

Bassler's  Gastric  Electrode. — This  instrument  is  practically  a  combina- 
tion of  Figs.  147  and  148.  It  has  the  usual  capsule  with  a  cord-like 
conducting  wire  and  also  an  introducer  (Fig.  149). 

The  latter  is  withdrawn  after  the  introduction  of  the  electrode.  After 
the  application  is  completed  the  electrode  is  removed  by  the  flexible 
conducting  cord. 

I  have  found  Lockwood's  electrode  easy  to  introduce  and  unobjec- 
tionable to  the  patient.     All  are  good  instruments. 


Fig.  149. — Bassler's  gastric  electrode 


Gastrofaradization. — Duration  ten  to  twelve  minutes.  The  intra- 
gastric electrode  is  attached  to  either  pole  with  this  current.  A  plate 
electrode  connected  with  one  pole  is  placed  in  the  epigastric  region  for 
four  or  five  minutes,  and  later  a  sponge.  The  electrode  is  then  moved 
from  left  to  right  several  times  in  the  gastric  region;  and  later,  if  marked 
constipation,  from  the  caput  coli  to  the  sigmoid  along  the  colon,  and  also 
over  the  umbilical  region.  The  application  over  the  stomach  occupies 
about  two  minutes.  The  electrode  is  then  placed  to  the  left  of  the 
seventh  dorsal  vertebra  for  one  to  two  minutes,  and  then  returned  to 
the  front  for  the  balance  of  the  time.  The  current  should  be  strong 
enough  to  cause  contraction  of  the  muscles,  but  not  produce  pain.  Appli- 
cation of  the  sponge  to  the  intestines,  occupies  several  minutes,  in  addition 
to  the  ten  minutes  over  the  stomach. 

Gastrogalvanization. — Duration,  eight  to  ten  minutes.  Contractions 
occur  only  at  the  make  and  break  of  the  galvanic  current.  The  strongest 
is  the  make  with  the  negative,  and  the  next  the  break  with  the  positive. 
A  small  sponge  electrode  is  placed  on  the  epigastrium.  The  intragastric 
electrode  is  connected  with  the  positive  pole  for  the  sedative  effect  with  a 
constant  current.     It  also  contracts  and  hence  decreases  secretion.     The 


LOCAL  TREATMENT  OF  THE  STOMACH  219 

Strength  of  the  current  should  average  15  to  25  milliamperes.  The  full 
strength  is  not  used  at  first.  The  application  is  two  minutes  to  the  epi- 
gastrium. It  is  then  moved  about  over  the  gastric  region  for  three  to 
four  minutes;  then  for  one  to  two  minutes  in  the  dorsal  region  as  described, 
and  the  balance  of  the  period  in  the  gastric  region. 

There  has  been  some  dispute  as  to  the  effects  of  these  currents  and  the 
indications  for  their  use.  In  general  we  may  say  that  direct  faradization 
increases  the  gastric  secretion,  while  galvanization  decreases  it. 

Faradization  affects  the  musculature  and  galvanization  the  sensory 
field.  The  claims  regarding  increase  in  absorptive  power  from  the  use 
of  electricity  seem  hardly  to  be  substantiated,  as  it  was  so  small  as  to  be 
within  normal  limits. 

Therapeutics. — The  percutaneous  method  has  proved  of  service  in 
nervous  anorexia  and  in  motor  insufficiency.  The  intragastric  method 
is  preferable  when  possible.  It  renders  some  patients  more  nervous, 
and  in  such  should  be  avoided. 

Among  the  indications  for  gastrofaradization  are:  Atonic  ectasia, 
atony,  relaxation  of  the  cardia  and  pylorus,  and  diminished  secretion. 

For  gastrogalvanization  they  are:  Gastralgias,  especially  of  nervous 
type,  nervous  anorexia,  and  hyperacidity. 

Faradization,  however,  has  proved  of  benefit  in  gastric  neuroses. 


Fig.  150. — ^Turck's  latest  gyromele. 

Triphase  Method. — HershelP  recommends  the  polyphase  or  triphase 
method  in  which  two  electrodes  are  placed  on  the  back  and  one  on  the 
abdomen  or  intragastrically. 

Static  Electricity. — This  has  been  recommended  especially  in  the 
atonic  types  of  ectasia,  claim  being  made  that  it  causes  contraction  of 
the  organ.     In  neuroses  it  is  sometimes  of  service. 

Tousey^  states  that  the  motor  functions  are  favorably  influenced  by 
the  static  indirect  current. 

High-frequency  Current. — This  method  is  scarcely  applicable  by  the 
general  practitioner,  but  I  believe  it  of  some  benefit  in  gastric  neuroses, 
in  atony,  and  for  hyperchlorhydria.  On  the  other  hand,  others  claim 
it  will  increase  HCl  if  deficient. 

Tousey  recommends  it  further  in  chronic  colitis,  fissure,  rectal  ulcer 
and  in  incontinence  of  the  sphincter.  Occasionally  it  has  proved  of  value 
in  hemorrhoids. 

^Archives  of  the  Roentgen  Rays,  1906,  1907,  vol.  xxi,  p.  221. 
^Medical  Electricity  and  Roentgen  Rays,  p.  400. 


220  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Tiirck's  d-yromele. — Tlirck  has  introduced  this  instrument  for  the 
local  treatment  of  the  stomach  and  colon.  It  consists  of  a  cable  with  a 
sponge  attachment,  which  can  be  made  to  revolve  within  an  outer  stomach- 
tube.  There  is  an  arrangement  so  that  medicated  fluids  can  flow  into  the 
stomach  or  colon  through  the  outer  tube,  and  also  an  attachment  for  a 
battery  pole.  He  advocates  its  use  for  catarrhal  gastritis  to  cleanse  the 
mucous  membrane.  It  can  also  be  employed  alone  for  internal  massage 
of  the  stomach  or  combined  with  electricity.  It  is  depicted  in  Fig.  150. 
The  author  questions  its  utility. 


CHAPTER  IX 

MASSAGE— VffiRATORY  MASSAGE— HYDROTHERAPY— 
COUNTERIRRITATION— ORTHOPEDIC  APPLIANCES 

MASSAGE 

Massage  of  the  stomach  is  indicated  in  atony  or  in  the  atonic  form  of 
dilatation  and  temporarily  to  aid  in  the  removal  of  gas.  The  intestines 
should  also  be  manipulated  in  these  conditions.  It  is  of  value  in  stimu- 
lating the  abdominal  muscles  in  gastroptosis.  I  will  briefly  refer  to  a  few 
simple  methods. 

If  massage  is  performed  on  the  absolutely  empty  stomach,  it  is  con- 
tracted and  cannot  be  palpated.  It  is  preferable  to  perform  it  two  or 
three  hours  after  a  meal.  This  aids  in  emptying  the  stomach.  Earlier 
manipulation  might  cause  vomiting. 

Contraindications  are  ulcer,  recent  hemorrhage,  and  acute  inflam- 
mation. 

The  patient  should  be  in  the  dorsal  position ;  lower  limbs  flexed.  The 
left  hand  of  the  operator  is  placed  on  the  right  hypochondrium  to  exert 
counterpressure  against  the  pyloric  end.  With  the  thumb  and  fingers 
extended,  the  right  hand  performs  stroking  motions  from  left  to. right  over 
the  stomach.  Then  the  stomach  is  kneaded.  These  procedures  should 
alternate.  This  technic  should  be  carried  out  daily  for  five  to  ten  minutes. 
With  dilatation  or  ptosis  of  the  stomach  the  direction  of  the  stroking 
must  be  adapted  to  the  position  of  the  organ  in  each  case. 

Tapping  (tapotement)  or  rapid  vibratory  movements  with  the  fingers 
can  be  employed.  It  is  often  well  to  rotate  the  patient  to  the  right  side 
during  massage,  so  as  to  aid  in  emptying  the  atonic  stomach. 

VIBRATORY  MASSAGE 

Various  vibrators,  especially  electric,  many  of  which  are  quite  expen- 
sive, have  been  devised  for  this  purpose.  Of  late,  vibrators  can  be  pur- 
chased at  a  reasonable  figure  which  can  be  attached  to  the  street  current^ 
in  the  patient's  residence.  The  method  is  very  convenient  when  the 
facilities  exist.  There  is  an  instrument  run  by  carbonic  acid  gas  pressure, 
which  necessitates  carrying  a  large  tank.  There  is  a  small  portable 
vibrator,  the  Vedee,  manipulated  by  hand  (Fig.  151),  which  is  cheap, 
simple  of  manipulation,  and  efiicacious.  The  strength  of  the  vibration 
is  regulated  by  changing  the  position  of  the  rotating  disk.  The  instru- 
ment can  be  employed,  with  the  addition  of  electricity,  by  attaching  a 
sponge  arranged  for  battery  connection  and  employing  the  other  pole 
with  a  sponge  over  the  abdomen.     Electric  vibratory  massage  can  thus 

'  The  Eureka  vibrator  is  convenient,  having  many  excellent  attachments 


222 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


be  given  over  the  stomach  and  intestines  (Fig.  152).  In  addition,  one 
battery  pole  can  be  attached  to  the  vibrator  and  the  other  to  the  intra- 
gastric electrode  for  treatment  of  atony  of  the  stomach. 


Fig.  151. — Vedee  vibrator  (new  model). 


Fig.   152. — Combined  electricity  and  vibratory  massage. 

There  are  other  small  hand  vibrators  now  manufactured  and  also 
small  vibrators  which  can  be  run  by  a  portable  storage  battery. 


VIBRATORY   MASSAGE 


223 


Fig.  153. — Massage  roller  with  demonstration  of  alternating  hot  and  cold  electric 
massage:  a,  Screw  cap;  h,  filling  tube;  c,  funnel  for  filling;  d,  attachment  for  battery 
pole.     (Author's  Instrument.) 


Fig.   154. — Combined  application  of  electricity  and  roller  massage  with  heat. 


224  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

Vibratory  massage  should  be  given  from  left  to  right  over  the  stomach 
for  about  three  minutes,  then  two  minutes  to  the  left  of  the  seventh 
dorsal  vertebra,  and  three  minutes  more  over  the  stomach.  This  should 
be  performed  daily. 

It  is  generally  advisable  to  vibrate  the  intestines,  following  the  course 
of  the  colon,  especially  over  the  sigmoid,  and  also  over  the  small  intestines. 
This  last  can  be  done  before  breakfast  to  stimulate  the  bowels.  Two  or 
three  hours  later  the  stomach  should  be  vibrated.  The  patient'^  family 
can  be  taught  to  use  this  instrument. 

Bassler  has  recently  devised  an  excellent  vibrator,  requiring  the  street 
current.     For  city  practice  a  good  electric  vibrator  is  preferable. 

Massage  Roller. — Various  instruments  have  been  devised,  but  the 
following  is  simple.  It  consists  of  a  revolving  cylinder,  which  can  be 
filled  with  hot  or  cold  water,  and  which  is  furnished  with  a  battery  at- 
tachment. Heat  or  cold,  or  with  an  instrument  attached  to  each  battery 
pole,  alternating  heat  and  cold,  combined  with  electricity,  can  be  applied 
(Fig.  153).  This  method  can  be  employed  for  abdominal  massage  in 
some  cases  of  chronic  constipation. 

I  have  found  the  method  next  depicted  of  some  value  in  stimulating 
atonic  conditions  of  the  gastro-intestinal  tract  (Fig.  154). 

LOCAL  HYDROTHERAPY 

Cold. — For  hemorrhage  or  acute  inflammation,  the  ice-bag  is  prefer- 
able to  the  Leiter  coil.  At  times  it  relieves  ulcer  pain  more  than  does 
heat. 

Priessnitz's  Compress. — A  towel  folded  several  times  is  dipped  in 
cold  or  warm  water,  then  wrung  out,  and  placed  over  the  stomach. 
Oiled  silk  or  gutta-percha  is  placed  over  it,  and  a  flannel  binder  applied 
to  keep  it  in  place.  A  temperature  of  50°  to  75°F.  or  warmer  if  desired 
can  be  employed. 

This  method  is  of  value  in  nearly  all  painful  diseases  of  the  stomach. 
The  compress  can  be  changed  two  or  three  times  a  day.  Some  patients 
do  better  with  the  cold,  others  with  the  warm  compress. 

Hot  Applications. — Moist  Heat. — For  cardialgia,  ulcer,  vomiting,  etc., 
hot  moist  applications  are  of  value.  Poultices  can  be  made  of  linseed, 
flaxseed,  or  bran,  boiled  in  water,  or  of  hot  bread  and  milk.  I  have  seen, 
hot  meal  or  hot  mashed  potatoes  used  in  country  practice. 

The  poultice  is  wrapped  in  gauze  or  cheese-cloth  and  applied  as  hot 
as  the  patient  can  bear  it.  Fresh  hot  poultices  are  continually  applied. 
There  is  an  apparatus  which  can  be  boiled  in  water,  wrapped  in  a  cloth, 
and  then  applied  over  the  cataplasm.     It  will  keep  it  constantly  hot. 

A  felt  sponge  dipped  in  boiling  water,  wrung  out,  and  covered  with 
oiled  silk  can  be  employed. 

Dry  Heat. — The  hot-water  bag,  hot  cloths,  a  light  tin  pie-plate,  heated 
in  the  oven  and  covered  with  flannel,  the  Japanese  hot  box  containing 
burning  punk,  are  all  useful.  A  continuous  hot-water  coil  has  been 
devised,  to  be  connected  with  a  faucet. 

In  the  illustration  (Fig.  155)  is  shown  a  continuous  steam  coil'  of  my 
*  Enteroclysis,  Hypodermoclysis,  and  Infusion,  1900. 


ORTHOPEDIC    METHODS 


225 


own.  The  steam  passes  through  a  metal  coil  plate  and  is  recondensed. 
Only  a  small  quantity  of  water  is  necessary  in  the  boiler.  The  tempera- 
ture can  be  regulated  by  the  coverings  of  the  plate  and  by  the  stop-cocks 
on  the  Y-branch  at  the  top  of  the  boiler,  thus  allowing  less  steam  to  enter 
the  coil.  The  coil  can  be  placed  over  a  moist  poultice  to  preserve  its 
heat.     In  general,  moist  compresses  are  preferable. 

The  Douche. — ^The  fan-douche  and  the  Scotch  douche,  played  over 
the  stomach  region,  alternating  cold  55°F.  and  warm  95°F,  for  about 
three  minutes,  may  have  a  tonic  effect.  Packs,  rubs,  baths,  and  the 
carbonated  bath  are  at  times  employed  for  the  general  tonic  efifect. 


C  --JE*-'  »— --  **3J»1*^; 


^^  STEAM.) 


h± 


Iamp 


TT 


Fig.  155. — Continuous  steam  coil  for  the  application  of  heat. 

COUNTERIRRITATION 

Mustard  and  flour  poultice  (equal  parts),  or  black  or  red  pepper,  i 
dram  (4.0)  to  the  pint  (500  c.c.)  of  boiling  water,  flannel  to  be  wet  therein, 
wrung  out,  and  appUed  with  an  oiled  silk  cover  or  a  turpentine  stupe, 
prepared  by  the  same  method;  also  spice  poultices  are  of  service.  The 
clay  poultice  (cataplasma  kaolini)  sold  also  as  antiphlogistine  is  useful  at 
times. 

ORTHOPEDIC  METHODS 

Mechanical  support  of  the  stomach  and  intestines  is  of  great  service. 
Many  nervous  symptoms  referred  to  the  gastro-intestinal  tract  can  be 
imputed  to  ptosis  of  the  viscera  and  relaxation  of  the  abdominal  walls. 
In  simple  atony  of  this  tract  the  proper  support  frequently  aids  the  bowel 
action. 


IS 


226 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


The  indications  for  mechanical  support  are  as  follows: 
Ptosis  of  any  or  all  of  the  viscera  from  any  cause;  atony  of  the  stomach; 
atonic  dilatation  of  the  stomach;  stenotic  ectasia  as  a  temporary  measure; 


Fig.  156. — Pattern  for  cutting  the  Rose  plaster  abdominal  binder:  Dotted  lines  for 

section. 


\~"i  ~~~----L'-"'"ir""'I 


Fig,  157. — Pattern  for  cutting  the  Rose  plaster  abdominal  binder:  Plaster  after  section. 

atony  of  the  intestines;  pains  from  intraabdominal  adhesions  dragging 
on  the  viscera;  hernia  of  the  abdominal  wall;  after  laparotomy  as  a  tem- 
porary support;  postpartum  to  prevent  ptosis  (Landau's  disease),  and 


Fig.  158. — Rose's  belt  (under  plaster): 
Step  one. 


Fig.  159. — Rose's  belt:   Step    two,  left 
wing. 


also  to  enable  the  patient  to  sit  up  in  bed  earUer  and  so  drain  the  uterus. 
This  last  was  suggested  by  me  to  Douglas  H.  Stewart,  who  has  reported 
successful  results.     Cases  of  constipation  in  which  atony  is  a  factor. 


ORTHOPEDIC    METHODS 


227 


Fig.  169. — Rose's  belt:  Complete. 


I'ig.  161. — Dorsal  view:  Under  plaster  with  overlapping'  ends  (Rose  and  Kemp). 


228 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


Pelvic  disturbances  which  are  associated  with  splanchnoptosis  and  result 
from  general  prolapse.  Mucous  colic  in  which  ptosis  is  a  factor.  Pendu- 
lous abdomen,  vomiting  of  pertussis  (T.  W.  Kilmer),  sea-sickness,  and 
nervous  vomiting. 

There  are  four  methods:  The  use  of  adhesive  plaster,  the  most  scien- 
tific; elastic  bandages,  special  corsets,  and  the  Lane  model  supporting  pad 
with  springs. 

To  A.  Rose  we  must*  credit  the  best  method  of  adhesive  strapping. 
The  author  first  suggested  the  use  of  zinc  oxid  on  moleskin  plaster,  from 
experiments  finding  it  most  suitable,  and  this  was  adopted  by  the  origi- 


Fig.  162. — Dorsal  view:  Plaster  dressing  complete  (Rose  and  Kemp). 

nator  of  the  method.     For  a  full  description  I  would  refer  to  our  work 
on  this  subject.^ 

The  method  is  as  follows:  Adhesive  plaster,  zinc  oxid  on  soft  mole- 
skin (Johnson  and  Johnson),  preferably  7  inches  wide,  though  6  inches 
can  be  employed.  A  yard  in  length  will  suffice  in  most  cases.  The 
circumference  of  each  patient  should  be  measured,  and  the  plaster  should 
be  long  enough  to  encircle  the  waist.  Rose  has  recently  recommended 
a  German  white  rubber  plaster  (Leukoplast)  spread  on  moleskin  or  canvas. 
I  can  see  no  advantage.  The  plaster  is  folded  over  so  that  the  free  ends 
*  Rose  and  Kemp,  Atonia  Gastrica. 


ORTHOPEDIC   METHODS 


229 


are  in  line  and  a  curved  line  drawn  in  pencil  from  the  lower  margin  of 
the  point  where  it  folds  to  the  free  margin,  to  about  i  inch  below  the 
upper  border.     The  plaster  is  cut  along  this  line,  giving  three  pieces;  or 


Fig.  163. — Application  of  narrow  strips 
of  adhesive  plaster:  First  step. 


Fig.  164. — Application  of  plaster:  Sec- 
ond step. 


the  plaster  is  stretched  out  and  the  dotted  lines  marked,  as  in  Fig.  156, 
and  cut  along  these  lines,  giving  three  pieces,  /  and  the  two  lateral  pieces, 
//,  ///,  as  in  Fig.  157. 


Fig.  165. — Application  completed. 

/  is  applied  to  the  abdomen,  and  the  lateral  pieces,  //,  ///,  overlap 
in  front  and  are  applied  to  the  under  plaster.  These  serve  to  draw  up 
the  abdomen. 


230 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


To  avoid  irritation  of  the  umbilicus,  I  cut  a  V  out  of  the  upper  border 
of  the  under  plaster  or  invert  a  small  portion  of  it.  The  sharp  angle 
below  should  be  cut  off  to  avoid  interference  with  the  pubic  hair.  The 
curved  portion  of  the  lateral  wings  should  look  upward  and  somewhat 
inward  and  adhere  to  the  lower  ribs.  The  sharp  angles  of  the  lateral 
wings  at  the  symphysis  may  also  be  cut  off  to  avoid  the  hair. 

Hair,  if  present  on  the  abdomen,  is  shaved  and  the  surface  cleaned 
with  ether  or  chloroform. 

The  plaster  is  applied  with  the  patient  in  the  dorsal  position,  with 
hips  well  elevated  and  preferably  in  the  Trendelenburg  position. 

Of  late  the  writer  has  augmented  the  upward  pressure  of  the  belt  by 


Fig.  i68. — Front  view.     Belt  complete. 
Figs.  166-168. — Rosewater  adhesive  plaster  belt  (Rose  and  Kemp). 


an  oblique  strip  2  inches  wide  from  the  median  Una  in  front  to  the  spine 
behind  on  each  side.  These  strips  should  overlap  slightly  over  the 
abdomen.  They  are  held  firmly  in  front  by  two  short  transverse  strips 
which  also  cause  additional  pressure.  To  secure  additional  upward  lift, 
a  two-inch  strip  of  plaster  is  applied  from  just  inside  the  crest  of  the  right 
ilium  in  a  downward  direction  toward  the  midsymphysis  (adherent  to  the 
other  plaster)  and  then  exerting  an  upward  pull,  it  is  gradually  curved 
upward  to  a  similar  level  inside  the  left  iliac  crest.  Extra  cross  strips  are 
applied  to  hold  it  firmly. 

In  the  illustrations  (Figs.  158 — 160)  are  shown  the  three  stages  of 
application  of  the  belt,  the  under  plaster,  one  wing  applied,  and  the 


ORTHOPEDIC   METHODS 


231 


Fig.  169. — Kilmer's  belt  stockinet  band:  Step  one. 


Fig.  1 70. — Kilmer's  belt  (complete) :  Elastic  webbing,  front. 


232 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


complete  contrivance.  In  Figs.  i6i  and  162  are  shown  the  rear  view 
during  application. 

The  plaster  should  remain  on  for  four  to  six  weeks,  depending  on  the 
season  of  the  year,  irritation  (which  is  rare),  or  its  loosening.  It  should 
then  be  removed,  a  full  bath  given,  talcum  dusted  on,  and  twenty-four 
hours  later  a  new  belt  applied. 

Oil  of  wintergreen,  applied  to  adhesive  plaster,  aids  its  easy  and  pain- 
less removal.  One  can  also  apply  to  the  plaster  a  10  per  cent.^  winter- 
green  oil  ointment. 


Fig.  171. — Kilmer's  belt  (complete):  Elastic  webbing,  rear. 


One  patient  sent  me  by  Wm.  H.  Thomson,  a  severe  case  of  splanchno- 
ptosis, wore  the  belt  fourteen  months,  gained  40  pounds  in  weight,  and 
was  completely  cured. 

The  device  gives  brilliant  results.  The  method  of  support  by  a  pad 
for  the  special  organ  is  unscientific. 

Only  on  occasions,  when  the  material  for  Rose's  belt  was  not  at  hand, 
have  I  applied  a  method  with  narrow  strips  of  plaster,  as  depicted  in 
Figs.  163-165.  They  overlap  at  the  linea  alba  in  front  and  at  the  spine 
behind.     As  the  final  procedure,  two  transverse  strips  are  applied  in  front. 

^  Beardsley,  Jour.  Amer.  Med.  Assoc,  Jan.  28,  1911. 


ORTHOPEDIC   METHODS 


233 


Fig.  173. — Improved  belt  (rear). 


234 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


Rosewater  Adhesive  Belt. — A  strip  of  zinc  oxid  plaster  of  sufficient 
length  and  2  to  3  inches  wide  is  fastened  to  the  abdomen  just  above  the 
pubes.  This  is  drawn  upon  upward  and  fastened  above  to  the  lower 
end  of  the  sternum.  Diagonal  strips  crossing  the  lower  end  of  the  vertical 
strip,  overlapping  behind  at  the  spine,  are  then  applied  (Figs.  166  and 
167). 

A  horizontal  strip  is  fastened  to  one  hip  and  stretched  across  the  pubes 


Fig.  174. — Teufel's  abdominal  supporter. 

to  the  other  hip,  overlapping  the  ends  of  the  other  plaster  and  acting  as 
an  additional  girdle  (Fig.  168). 

Plaster  strapping  affords  continuous  support  during  treatment  which 
other  methods  do  not.  Numerous  modifications,  with  and  without  eyelet 
holes  for  lacing,  have  been  devised,  but  those  described  are  the  most 
practical. 


175. — Abdominal  supporter. 


Fig.   176. — Abdommal  supporter. 


Kilmer's  Abdominal  Belt. — An  ingenious  belt  was  devised  some 
years  ago  by  T.  W.  Kilmer  for  the  relief  of  vomiting  in  pertussis.  The 
original  belt  consisted  of  a  stockinet  band  applied  as  in  Fig.  169.  Around 
this  was  wound  a  strip  of  silk  elastic  webbing,  which  could  be  pinned  or 
sewed  on,  as  in  Figs.  170  and  171. 

The  apparatus  extends  from  just  above  the  hips  and  symphysis  well 
up  on  the  thorax.  The  relief  of  vomiting  and  cough  is  quite  remarkable 
in  pertussis. 


ORTHOPEDIC   METHODS 


235 


Recently,  Kilmer  reports  a  simplified  belt  made  of  linen,  with  strips 
of  elastic  webbing  inserted  on  either  side.  It  laces  up  the  back  (Figs. 
172  and  173). 

The  belt  should  measure  slightly  less  (2  to  3  inches)  than  the  circum- 
ference at  the  navel.  The  degree  of  constriction  should  be  determined 
in  every  case.  This  belt  is  valuable  for  the  prevention  of  seasickness,  for 
nervous  vomiting,  and  as  an  abdominal  support.    The  cost  is  slight. 


177. — Lane's  abdominal  supporter  (Curtis  Spring  Pad). 


-Various  tj^es  of  silk  elastic  belts  are  employed 
174-176.     Storm's   abdominal   supporter    is   also 


Silk  Elastic  Belts. 

as   pictured   in   Figs, 
excellent. 

Sir  Arbuthnott  Lane's  abdominal  supporter  (the  Curtis  spring  pad) ,  a 
broad  leather  pad  which  exerts  upward  pressure  from  the  symphysis  to 
the  umbilicus  is  depicted  in  Figs.  177  and  178.  It  is  held  in  position  by 
springs  similar  to  those  employed  in  a  truss — extending  on  each  side  to 


Fig.  178. — Lane's  abdominal  supporter  in  position. 

the  spine.     He  employs  it  in  cases  of  enteroptosis — with  kinks  and  intes- 
tinal stasis  treated  medically. 

Special  Corsets. — A  valuable  support  of  this  type  is  that  of  E.  Gal- 
lant, which  is  depicted  under  Gastroptosis.  The  La  Grecque  surgical 
corset  is  also  useful,  and  is  illustrated  in  the  same  chapter.  The  latter 
is  frequently  employed  by  the  writer. 

^  Archives  of  Pediatrics,  February,  1907. 


CHAPTER  X 
CATARRH  OF  THE  STOMACH 

ACUTE  AND  CHRONIC  GASTRITIS 
Acute  Gastritis 

Acute  gastritis  may  be  defined  as  an  acute  inflammation  of  the  gastric 
mucous  membrane  with  resulting  disturbances  of  digestion.  It  is  of 
different  degrees  of  severity,  being  limited  to  the  superficial  layer  of  the 
mucous  membrane,  or  it  may  extend  to  the  glandular  parenchyma  or 
involve  the  interstitial  tissues. 

It  is  subdivided  into  simple  acute  gastritis,  toxic  gastritis,  and  phleg- 
monous gastritis. 

Simple  Acute  Gastritis 
(Synonyms. — Acute  Gastric  Catarrh;  Acute  Gastric  Dyspepsia.) 

Etiology. — Simple  acute  gastric  catarrh  is  one  of  the  most  frequent 
diseases  met  with  by  physicians.  It  occurs  in  all  classes  of  society  and 
at  all  ages.  It  may  be  primary  or  secondary  to  another  disease.  One 
of  its  frequent  causes  is  some  irritant,  mechanic,  chemic,  or  thermal; 
thus,  errors  in  diet,  or  too  large  a  quantity  of  food  that  has  been  im- 
perfectly masticated  or  rapidly  bolted;  too  hot  or  too  cold  food  or  drink; 
too  highly  spiced  or  fermented  foods;  rancid  butter;  unripe  or  spoiled 
fruit;  spoiled  food  or  drink,  or  overindulgence  in  alcohol. 

Fermentation  or  putrefaction  are  most  apt  to  occur  in  food  during  the 
summer,  and  these  factors  probably  account  for  the  epidemics  occurring 
at  that  season,  though  infection  has  been  suggested.  Such  cases  generally 
occur  as  gastro-enteritis. 

Bacterial  infection  of  food  may  be  a  cause,  as  the  colon  bacillus  in  milk, 
or  meat,  or  sausage  poisoning. 

Primary  mycosis  of  the  stomach,  the  favus  fungus;  schizomycetes; 
parasites,  as  the  larvae  of  flies  (myiasis);  ascarides,  oxyuris  and  taenia,  by 
entering  the  stomach,  and  abdominal  burns  are  rare  causes.  Acute 
catarrhal  or  suppurative  conditions  of  the  nose  and  throat  may  produce 
acute  gastritis  from  the  ingestion  of  discharges.  Pyorrhea  alveolaris  and 
poor  teeth  may  be  factors.  I  have  recently  seen  one  such  case,  and  the 
patient,  suffering  from  acute  gastritis,  cured  by  treatment  of  the  source. 

Some  persons  have  a  predisposition  to  a  "weak  stomach,"  and  this 
condition  seems  almost  to  be  hereditary.  Others  have  been  trained  to 
such  a  simple  diet,  as  the  children  of  dyspeptics,  that  the  stomach  cannot 
perform  its  normal  amount  of  work  and  readily  becomes  irritated.  In 
old  persons,  invalids,  or  anemic  women  the  organ  is  readily  affected. 

Acute  gastritis  may  be  secondary  to  the  acute  infectious  diseases,  such 
as  measles,  typhoid,  variola,  pneumonia,  etc.,  or  as  a  sequel  of  acute 
nephritis.     I  have  seen  an  attack  follow  prolonged  anesthesia. 

236 


CATARRH    or   THE    STOMACH 


237 


A  diphtheritic  or  membranous  gastritis  has  been  met  with  in  diph- 
theria, anthrax,  or  as  a  secondary  process  in  typhoid,  typhus,  pneumonia, 
etc.  It  cannot  be  diagnosed  unless  the  membranes  are  vomited.  Diffuse 
acute  gastritis  is  reported  to  have  occurred  with  syphiHs. 

Morbid  Anatomy. — Acute  gastritis  is  characterized  by  an  acute  in- 
flammation of  the  superficial  layers  of  the  mucosa,  with  an  increased 
secretion  of  mucus  and  a  desquamation  of  the  epithelial  cells. 

The  mucous  membrane  is  reddened  and  swollen,  less  gastric  juice 
is  secreted,  and  mucus  covers  the  surface.  The  swelling  is  diffuse  or  in 
circumscribed  areas.  There  are  sometimes  slight  hemorrhages  and 
small  erosions  or  sacculations  of  the  mucous  membrane.  The  sub- 
mucosa  may  be  edematous.     The  pyloric  end  is  more  frequently  affected. 


Fig.  179. — Acute  gastritis:  Round-celled  infiltration  in  the  interglandular  struc- 
ture. Dark  clumps  represent  hemorrhagic  areas.  (From  Bassler's  "Diseases  of  the 
Stomach  and  Upper  Alimentary  Tract."     Copyright,  igro,  by  F.  A.  Davis  Company.) 

Gastric  secretion  is  weakly  acid,  neutral,  or  even  alkaline  and  diminished 
in  quantity.  Beaumont,  from  his  observations  on  St.  Martin,  has  given 
an  excellent  description. 

Microscopic. — The  superficial  epithelial  layer  is  partially  loosened 
or  in  a  condition  of  cloudy  swelling.  The  parietal  and  principal  cells  can- 
not be  distinguished  apart;  they  are  granular  and  in  a  condition  of  cloudy 
swelling  and  fatty  degeneration,  and  are  shrunken.  The  capillaries  are 
dilated  and  round  cells  are  found  in  the  interglandular  tissue,  between 
the  epithelial  cells  and  on  the  surface  (Fig.  179).  Karyokinesis  may  be 
present. 

Bacteria  are  commonly  found  present,  of  which  the  most  frequent 
types  are  the  Bacillus  lactis  aerogenes.  Bacillus  coli  communis,  proteus 
vulgaris,  oidium  albicans,  and  streptococci. 


238  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Symptoms. — These  vary  according  to  the  severity  of  the  attack. 
There  are  loss  of  appetite,  discomfort,  fulness  or  pressure  in  the  region 
of  the  stomach,  belching  of  gas  which  may  taste  sour,  and  occasional 
nausea.  In  some  cases  there  are  no  rise  of  temperature  and  no  vomit- 
ing, and  the  symptoms  pass  off  in  a  day  or  two;  the  bowels  are  costive 
or  diarrhea  is  present. 

In  more  severe  cases  there  are  pains  in  the  gastric  region,  headache, 
nausea,  vomiting  (prolonged  and  excessive),  first  of  food,  then  chiefly 
of  mucus,  at  times  streaked  with  blood,  and  frequently  bilious  vomiting. 
There  may  be  considerable  prostration.  Often  there  is  an  acid  taste  in 
the  mouth.  There  is  generally  a  temperature,  sometimes  rising  to  102° 
to  io4°F.,  and  at  times  chills,  and  the  tongue  is  usually  coated  and  swollen. 
The  pulse  is  frequently  rapid  and  feeble. 

In  the  cases  due  to  ingestion  of  spoiled  food,  etc.,  auto-intoxication 
undoubtedly  results  and  aggravates  the  symptoms. 

Vomiting  usually  follows  the  introduction  of  the  irritant,  but  is  some- 
times delayed  for  some  hours,  and  food  is  found  that  was  ingested  twelve 
or  fifteen  hours  before,  a  condition  of  acute  motor  insuflSciency.  Consti- 
pation or  diarrhea  is  present.  The  early  vomitus  often  has  a  disagree- 
able odor  and  contains  food  remnants.  The  reaction  is  slightly  acid  and 
free  hydrochloric  acid  is  often  absent.  Lactic  and  other  organic  acids 
are  at  times  present.  Occasionally  a  duodenitis  with  jaundice  is  associated. 
Herpes  labialis  is  quite  frequent. 

Physical  Examination. — The  region  of  the  stomach  is  usually  distended 
and  sensitive,  and  may  be  tender  on  pressure. 

Urine  is  scanty,  dark  in  color,  of  high  specific  gravity,  urates  are 
marked,  and  occasionally  indican  and  albumin  are  present. 

Duration. — This  is  usually  short,  from  two  to  three  days,  though  at 
times  prolonged  to  a  week. 

Diagnosis. — Some  of  the  infectious  diseases,  notably  scarlatina,  begin 
like  the  febrile  form  of  acute  gastritis,  and  one  should  always  be  on  the 
watch  for  such  an  occurrence. 

In  rare  cases  the  symptoms  are  intensely  severe,  headache  and  even 
delirimn  being  so  marked  as  to  have  been  mistaken  for  meningitis.  In 
the  latter  case,  Kernig's  sign  can  be  elicited  and  lumbar  puncture  is  an 
aid  to  diagnosis. 

In  biliary  coUc,  with  acute  vomiting,  the  pain  radiates  to  the  right 
side  or  right  shoulder,  and  pain  over  the  gall-bladder  is  present. 

In  cholecystitis,  with  or  without  calculi,  with  little  or  no  pain  and 
no  jaundice,  but  vomiting,  the  diagnosis  is  more  difficult.  The  previous 
history,  tenderness  over  the  gall-bladder,  and  the  presence  of  leukocytosis, 
especially  the  increase  in  the  polynuclears,  are  significant.  Hyperchlor- 
hydria  is  frequently  associated.  The  presence  of  Head's  gall-bladder 
zone  of  cutaneous  algesia  aids  diagnosis. 

With  peritonitis,  we  have  muscular  rigidity,  leukocytosis,  increased 
polynuclears,  marked  abdominal  tenderness,  and  distention. 

With  nervous  gastralgia,  the  material  vomited  is  usually  very  acid 
(hyperchlorhydria),  no  mucus,  and  there  is  the  nervous  history. 

Castrosuccorhea  has  been  occasionally  diagnosed  incorrectly  as  bilious 


CATARRH  OF  THE  STOMACH  239 

vomiting.  Hypersecretion  occurs  most  frequently  at  night;  the  vomitus 
is  very  acid,  a  high  content  of  HCl.  With  biUous  vomiting — (gastro- 
enteritis)— the  vomitus  is  weakly  acid,  neutral  or  even  alkaline  and 
contains  bile.  Reichmann's  test  may  furthermore  be  employed  to  dif- 
ferentiate. Wash  out  the  stomach  on  retiring — withhold  all  food  and 
drink.  On  aspiration  of  stomach  twelve  hours  later  50  to  125  c.c.  of 
acid  gastric  contents  are  obtained — diagnostic  of  hypersecretion. 

With  typhoid  fever,  we  have  the  gradual  rise  of  temperature,  increas- 
ing daily,  the  splenic  enlargement,  frequently  the  eruption,  often  bron- 
chitis, Ehrlich's  diazo  and  the  Widal  reactions;  while  with  acute  gastritis 
the  rise  of  temperature  is  sudden  and  the  fall  equally  sudden,  and  there 
are  the  absence  of  splenic  enlargement  and  other  symptoms. 

When  jaundice  is  associated  with  acute  gastritis,  the  duodenum  has 
evidently  become  involved.  The  gastric  crises  of  locomotor  ataxia  have 
been  mistaken  for  acute  gastritis,  but  the  absence  of  knee-jerks,  the  Rom- 
berg symptom,  and  Argyll-Robertson  pupil  are  diagnostic  of  tabes. 

Prognosis. — This  is  favorable,  except  in  very  old  peqple,  infants  and 
invalids. 

Treatment. — Prophylaxis. — In  patients  subject  to  attacks  of  acute 
gastritis,  excess  in  eating,  rich  food,  lobster,  food  and  drink  that  are  too 
hot  or  cold,  or  any  articles  for  which  they  have  an  idiosyncrasy  should 
be  forbidden.  Candy  and  cake  should  not  be  allowed.  Unripe  and 
dirty  fruit  should  be  avoided.  With  infants,  care  should  be  taken  as 
to  the  storage  of  milk  and  its  preparation. 

If  the  acute  gastritis  be  due  to  ingestion  of  improper  food,  there  are 
two  principles  to  follow:  Clear  out  the  gastro-intestinal  tract  and  give 
rest  to  the  stomach.  If  there  are  other  factors,  the  first  consideration 
does  not  apply.     In  all  cases  rest  in  bed  should  be  enjoined. 

In  the  mild  cases,  with  nausea  but  no  vomiting,  castor  oil,  i  to  iH 
ounces  (32.0-48.0);  or,  if  there  is  doubt  of  this  being  retained,  then 
calomel,  2  to  5  grains  (0.125-0.3),  or  blue  mass,  5  grains  (0.3),  followed 
in  twelve  hours  by  a  saline,  such  as  a  wineglass  of  Apenta,  or  citrate 
of  magnesia  (wineglass),  or  magnesium  sulphate,  i  to  2  drams  (4.0- 
8.0),  should  be  administered.  Laxol,  a  preparation  of  castor  oil  without 
the  disagreeable  taste  (practically  castor  oil  5  i  with  oil  of  cinnamon  gtts. 
5-x),  is  often  well  borne  in  the  same  dosage  as  castor  oil. 

If  much  nausea,  calomel,  Ko  grain  (0.006),  with  sodium  bicarbonate, 
H  grain  (0.0325),  every  hour  for  eight  or  ten  doses  is  useful,  followed  by 
a  saline  cathartic.     Other  combinations  are  given  shortly. 

Children  should  receive  proportionately  small  doses  of  cathartics. 

For  eructation  of  acid  fluid  (pyrosis),  bismuth  subnitrate,  3  grains 
(0.2),  with  sodium  bicarbonate,  3  grains  (0.2),  every  hour  or  two;  or 
magnesia  usta,  }i  ounce  (16.0),  with  sodium  bicarbonate,  H  ounce  (16.0), 
dose  as  much  as  covers  the  point  of  a  knife,  every  three  hours. 

For  nausea  or  vomiting,  oxalate  of  cerium,  i  grain  (0.065),  every  hour 
for  several  doses,  or  bismuth  subnitrate,  2  to  4  grains  (0.125-0.25), 
alone,  or  with  sodium  bicarbonate,  same  dose;  or  gelatin  (i  per  cent, 
solution,  dose  i  dram  (4.0),  every  hour,  given  cold;  or  milk,  8  ounces 
(250.0  c.c),  with  oxalate  cerium,  10  grains  (0.6)  and  sodium  bicarbonate, 


240  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

lo  grains  (0.6),  packed  in  ice;  dose,  i  dram  (4.0)  every  hour;  or  Fowler's 
solution  of  arsenic,  i  minim  (0.06),  every  hour  for  four  doses,  are  of  value. 
This  last  is  very  efficacious. 

Teaspoonful  doses  of  very  hot  water  or,  occasionally,  a  piece  of  cracked 
ice,  or  white  of  raw  egg  beaten  up  and  given  cold  in  i-dram  doses  (4.0), 
every  half -hour  to  an  hour,  are  useful. 

Cocaitif  carbolic  acid,  or  creosote  I  strongly  deprecate.  Heat  should  he 
applied  to  the  abdomen. 

Application  of  Heat. — A  hot-water  bag,  one- third  full  to  avoid  weight; 
a  Japanese  hot  box,  a  light  hot  salt-bag,  a  thin  tin  pie-plate  heated  in 
the  oven  and  covered  with  flannel;  or  moist  heat  by  means  of  a  flaxseed 
poultice,  hot  mashed  potato,  or  bread  poultice  in  country  practice;  mus- 
tard and  flour  poultice  (equal  parts);  or  black  or  red  pepper  poultice — 
1  dram  (4.0)  to  i  pint  (500  c.c.)  of  boiling  water — and  wring  out  flannel 
in  the  same  and  apply,  covering  with  oiled  silk. 

If  the  discomfort  is  marked,  then  give  warm  salt  water,  ^^  to  i  dram 
(2.0-4.0)  of  salt. to  8  ounces  (250  c.c.)  of  water,  and  tickle  the  fauces  to 
promote  vomiting,  or  perform  lavage. 

Small  doses  of  hot  water  may  be  given  to  relieve  thirst  and  food  should 
be  avoided  for  twenty-four  hours. 

If  small  quantities  of  nourishment  be  given,  I  have  found  i  ounce 
(32.0)  doses  every  hour  of  a  5  per  cent,  gelatin  solution  (in  a  glass  packed 
in  ice)  of  special  value,  or  small  quantities  of  milk  and  lime-water  (equal 
parts),  or  peptonized  milk  or  koumiss  or  albumen  water,  or  egg  white, 
beaten  up  cold. 

In  severer  cases,  the  stomach  should  be  emptied,  preferably  by  lavage, 
I  to  2  ounces  (32.0-64.0)  of  Phillips'  milk  of  magnesia  to  2  quarts  (liters) 
of  warm  water  being  excellent  for  this  purpose.  Plain  warm  water  or 
normal  salt  solution  may  be  employed. 

I  frequently  administer  calomel,  3  to  5  grains  (0.2-0.3),  and  sodium 
bicarbonate,  5  grains  (0.3),  in  a  little  water,  through  the  stomach-tube 
after  lavage  before  withdrawal  of  the  tube.  This  is  generally  retained, 
with  resulting  thorough  clearing  of  the  bowels.  Saline  solution  should 
not  be  employed  for  lavage  if  calomel  is  thus  given. 

Later  an  enema  of  a  saturated  solution — 2  to  3  ounces  (64.0-96.0) — 
of  magnesium  sulphate,  or  a  recurrent  enteroclysis  with  normal  saline 
solution  at  iio°F.  should  be  administered  (several  quarts — liters),  or  a 
soapsuds  enema,  i  quart  (liter),  containing  olive  oil,  6  ounces  (200  c.c), 
may  be  substituted.  Even  if  the  calomel  be  omitted,  it  is  of  great  im- 
portance to  move  the  bowels.  If  the  case  is  not  due  to  ingestion  of 
irritating  food,  then  bismuth  subnitrate,  oxalate  of  cerium,  a  few  doses  of 
Ko  grain  (0.006)  of  calomel  every  hour,  sodium  bicarbonate,  etc.,  may 
be  tried  for  a  brief  period;  and  if  these  fail,  lavage  should  be  performed. 
Gelatin  solution  or  white  of  egg  often  are  of  value  in  such  cases. 

If  jaundice  is  associated  due  to  a  complicating  duodenitis,  as  soon  as 
vomiting  is  relieved  by  lavage — treatment  for  this  condition  should  be 
instituted — and  remedies  should  be  given  to  liquefy  the  bile.  Those  em- 
ployed for  cholecystitis  or  cholelithiasis  are  of  service.  Generally  the 
writer  begins  with  soda  bicarbonate  5ss  in  vichy  twice  or  three  times 


CATARRH  OF  THE  STOMACH  24 1 

daily.  The  salicylates  are  of  service  such  as  sodium  salicylate  gr.  3-5 
t.i.d.  in  capsules.  The  best  form  to  administer  them  are  as  probilin  pills. 
The  formula  is  as  follows : 

I^.  Acid  salicylic gm.  2 

Natr  olein gm.  8 

Natr  stear gm.  4  \  No.  i 

Phenolphthalein gm. 

Camph.  menth gm.  3  i 

Ft.  pill.  No.  100. 

Three  to  four  pills  are  given  morning  and  night.  Some  administer 
them  with  a  pint  of  hot  water — but  the  writer  prefers  to  give  them  directly 
after  meals  or  two  to  three  pills  t.i.d.;  oleic  acidlU.  v  t.i.d.  in  soft  gelatin 
capsules  is  also  of  service.  If  infection  of  the  gall-bladder  complicate, 
hexamethylenamin  gr.  v  to  gr.  x  t.i.d.  is  a  valuable  adjunct,  given  with 
an  equal  amount  of  sodium  benzoate.  This  is  also  a  good  prophylactic 
against  infection  and  I  usually  give  it.  Apply  heat  to  epigastrium  and 
give  saline  irrigations  cool  80  or  9o°F,  or  hot  at  ii5°F.,  of  the  bowel. 

No.  2 

I^.  Bile-salts  (Fairchild) gr.  i    ]  This  may  be 

Succinate  of  soda gr.  5    l  substituted 

Phenolphthalein gr.  J^  J  for  No.  i . 

One  capsule  t.i.d.  and  at  bedtime  can  be  substituted  or  else  succinate  of 
soda  gr.  v  t.i.d. 

The  following  is  also  excellent: 


I^.  Sodium  glycocholate 5i 

Sodium  salicylate grs.     75 

Pancreatin grs.  150 

Sodium  bicarbonate grs.  150 

M.,  Dir.  in  capsule  No.  90. 
Sig. — Two  to  three  capsules  t.i.d.  after  meals. 


No.  3 


Phosphate  of  soda  or  sprudel  salts  (powder)  5i~3ii>  may  be  alter- 
nated once  every  day — or  apenta  or  some  other  saline  cathartic  water. 
For  several  weeks,  once  a  week  give  blue  mass  gr.  3-v. 

The  insertion  of  the  duodenal  tube  and  lavage  of  the  small  intestine 
with  a  quart  of  normal  saline  solution  in  which  5ss-3i  of  sodium  bicar- 
bonate has  been  dissolved  may  be  of  benefit  in  obstinate  cases  of  jaundice 
(obstructive)  due  to  catarrhal  duodenitis.  The  alkali  helps  dissolve  the 
mucus.  This  procedure  may  be  carried  out  every  other  day,  or  less 
frequently.  The  solution  is  allowed  to  flow  slowly  into  the  duodenum — • 
and  is  not  siphoned  out — but  should  wash  through  the  intestine.  The 
temperature  of  the  solution  should  be  101°  to  103 °F. 

Enteroclysis  (recurrent)  with  normal  saline  solution  or  high  enemata 
I  quart — at  a  temperature  of  115°  to  i2o°F.  should  be  given  daily.  Some 
do  better  with  cold  enemata  at  70°  to  8o°F.  but  if  there  is  renal  disturb- 
ance, heat  is  preferable. 

Diet. — This  should  consist  of  milk  and  vichy,  mixed,  zoolak,  koumyss, 

lactone  buttermilk,  rice  gruel  and  barley  gruel,  until  marked  improvement 

occurs,  when   toast,  chicken   broth,  oyster   broth,  boiled  rice,  crackers, 

toast  baked  in  the  oven,  raw  and  soft  boiled  eggs  may  be  added,  with  a 

16 


242  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

gradual  return  to  full  diet.  The  disappearance  of  bile  from  the  urine  shows 
that  the  obstruction  to  the  exit  of  bile  has  ceased.  The  conjunctivae  and  skin 
take  longer  to  clear  up — that  is,  for  the  coloring  matter  to  absorb.  The 
urine  should  frequently  therefore  be  carefully  examined  as  to  the  presence  of 
bile. 

With  bilious  vomiting,  lavage  should  be  employed  at  once,  as  there 
is  practically  reversed  peristalsis  with  an  open  pylorus,  and  the  con- 
tinuous accumulation  of  bile  in  the  inflamed  stomach  keeps  up  the  vomit- 
ing. Enteroclysis  should  be  used  after  lavage  (within  one  hour)  to 
promote  normal  peristalsis. 

It  may  be  necessary  to  wash  the  stomach  several  times,  but  it  is  the 
best  method  to  check  vomiting. 

In  the  severe  cases,  due  to  ingestion  of  improper  food,  it  is  my  opinion 
that  calomel  should  be  given  directly  after  lavage,  even  though  some  of 
it  be  vomited,  as  auto-intoxication  is  a  factor,  in  which  event  plain  water 
should  be  used  for  lavage. 

In  addition  to  the  milk  of  magnesia,  if  tne  vomitus  is  very  foul,  I 
add  lo  grains  (0.6)  resorcin  to  the  fluid  for  lavage  and  wash  with  the 
patient  both  in  the  erect  and  lying-down  position.  I  do  not  care  for 
apomorphin,  Ho  grain  (0.006),  ipecac,  or  tartar  emetic  to  empty  the 
stomach. 

If  there  is  considerable  prostration,  enemata  of  hot  normal  salt  solu- 
tion (ii5°-i2o°F.)  and  strychnin  by  hypodermic — >^o  to  Ho  grain 
(0.00108-0.002) — may  be  necessary,  or  even  5  grains  (0.3)  camphor  in 
20  minims  almond  oil  by  hypodermic. 

In  rare  cases,  when  there  has  been  much  vomiting  and  the  patient 
is  exhausted,  codein,  }^  to  K  grain  (0.008-0.016),  by  hypodermic,  or  the 
same  amount  of  morphin  may  be  used.  I  sometimes  employ  a  single 
dose  after  lavage  to  quiet  the  patient.  A  suppository — i  grain  (0.064) 
opium,  or  H  grain  (o.oi6)  morphin  with  H  grain  (0.021)  extract  bella- 
donna— may  be  substituted. 

Diet. — Entire  abstinence  from  food  during  the  first  twenty-four  hours 
or  longer  is  preferable;  nutritive  enemata  may  be  given  and  injections 
(rectal)  of  hot  saline  solution  to  relieve  thirst. 

For  the  latter,  i-dram  (4.0)  doses  of  hot  water  by  mouth,  or  of  a  cold 
I  to  2  per  cent,  gelatin  solution  are  preferable  to  cracked  ice.  The 
gelatin  seems  to  have  an  excellent  effect.  Proctoclysis  is  also  excellent 
for  the  same  purpose. 

Later,  small  doses  of  cold  gelatin  (5  per  cent,  solution)  or  milk  and 
lime-water  (equal  parts)  can  be  given,  or  milk,  8  ounces  (250  c.c),  with 
sodium  bicarbonate,  10  grains  (0.6),  and  cerium  oxalate,  10  grains  (0.6), 
in  H-  to  i-ounce  (16.0-32.0)  doses,  given  cold,  every  two  or  three  hours. 

White  of  egg  beaten  up  and  given  cold;  barley-water  alone  or  with 
milk  (equal  parts);  rice  gruel,  very  thin,  made  from  rice  flour  (Park  and 
Tilford)  with  milk  may  be  added. 

Later,  add  eggs  (soft  boiled),  scraped  raw  beef,  pigeon  (boiled), 
calves'  brains,  zwieback,  broths,  soups,  bouillon,  boiled  chicken,  and 
gradually  increase  to  full  diet. 

If  after  the  acute  attack  has  subsided  the  patient  suffer  from  a  feeling 


CATARRH    OF    THE    STOMACH  243 

of  pressure  and  discomfort,  dilute  hydrochloric  acid  may  be  given  to  aid 
digestion. 

IJ.  Acid,  hydrochlor.  dilut : Siiss  (lo.o); 

Aq.  destil q.  s.    ad.    5ij    (^60.0). 

Sig. —  3j  to  ij  (4.0-8.0),  in  water,  t.i.d. 

The  same,  combined  with  small  doses  of  tincture  of  nux  vomica, 
5  minims  (0.3)  in  each  dose,  or  with  compound  tincture  of  cinchona,  10 
minims  (0.6)  in  each  dose,  may  be  given. 

These  remedies  should  be  administered  one-half  hour  after  meals 
or  the  same  time  before.  Oxyntin  capsules  with  nux  vomica,  one  to  two 
capsules  t.i.d.,  a.  c.  or  p.  c,  are  an  excellent  substitute. 

TOXIC  GASTRITIS 

Etiology. — ^This  most  intense  form  of  inflammation  of  the  stomach  is 
caused  by  the  swallowing  of  concentrated  mineral  acids  or  strong  alkalis, 
or  by  poisons,  such  as  phosphorus  or  arsenic.  Among  such  acids  are 
nitric,  sulphuric,  hydrochloric,  oxalic,  and  carbolic;  the  caustic  alkalis; 
as  caustic  potash,  caustic  soda,  soap  lees,  and  strong  ammonia;  alcohol, 
phosphorus,  arsenic,  potassium  cyanid,  corrosive  sublimate,  and  potas- 
sium chlorate.  The  effects  are  more  severe  on  the  empty  stomach. 
Croton  oil  may  also  produce  this  condition. 

Anatomy. — The  acids  and  alkalis  destroy  the  parts  they  come  in 
contact  with,  causing  various  degrees  of  sloughing  of  the  mucous  mem- 
brane. They  may  penetrate  the  submucosa  or  the  entire  stomach  wall 
and  produce  perforative  peritonitis. 

Alcohol,  phosphorus,  or  arsenic  cause  an  acute  inflammation  of  severe 
type,  the  mucous  membrane  becoming  swollen  and  superficially  necrotic, 
with  hemorrhagic  spots  in  the  submucosa,  and  there  is  fatty  degeneration 
of  the  epithelia  of  the  glandular  tubuli. 

Symptoms. — There  is  intense  pain  in  the  gastric  region.  Violent  and 
burning  in  character,  and  increased  on  pressure;  and  frequently  pain  in  the 
pharynx  and  esophagus  (along  the  sternum).  There  are  salivation,  diffi- 
culty in  swallowing,  and  usually  vomiting,  constant  and  repeated,  which 
fails  to  relieve  the  pain.  This  is  generally  immediate,  though  not  always 
so.  There  may  be  food  remnants  in  the  vomit,  mucus,  streaks  of  blood, 
and  even  shreds  of  mucous  membrane.  The  abdomen  is  tender,  at  times 
distended,  though  occasionally  contracted.  Symptoms  of  collapse  often 
appear,  the  face  is  pale  and  anxious,  the  skin  pale  and  extremely  cold, 
pulse  rapid  and  feeble,  respiration  rapid  and  shallow.  There  are  restless- 
ness and  sometimes  convulsions. 

Albumin  and  blood  often  are  present  in  the  urine  and  petechiae  under 
the  skin.  The  writer  has  recently  seen  a  fatal  case  of  bichlorid  poison- 
ing with  marked  hemorrhagic  tendency,  subcutaneous,  intestinal,  and 
gastric.  Peritonitis,  shock,  or  respiratory  or  cardiac  failure  may  cause 
the  fatal  issue. 

Some  cases  are  more  protracted.  There  may  be  jaundice  or  hema- 
turia, or  intestinal  ulceration,  or  degeneration  of  the  liver  or  kidneys. 


244  DISEASES   OF   THE    STOMACH   AND    INTESTINES 

Phosphorus  poisoning  may  produce  hemorrhagic  jaundice  and  S5miptoms 
simulating  acute  yellow  atrophy  of  the  liver. 

Stricture  of  the  esophagus,  pylorus,  or  cardiac  orifice  of  the  stomach 
may  result  from  the  damaged  mucous  membrane,  with  corresponding 
symptoms,  such  as  dilatation  of  the  stomach,  etc.  In  rare  cases  atrophy 
of  the  mucous  membrane  (achylia  gastrica)  follows,  or  hour-glass  stomach, 
or  perigastric  adhesions. 

Diagnosis  is  usually  easy.  The  sudden  appearance  of  violent  gastric 
symptoms  in  a  perfectly  healthy  subject  should  excite  suspicion. 

Inspection  of  the  lips,  mouth,  and  tongue  will  show  the  effect  of  corro- 
sive poison,  if  such  have  been  taken,  and  examination  of  the  vomitus  and 
odor  of  the  breath  may  afford  information.  Inspection,  if  possible,  of 
the  receptacle  from  which  the  substance  was  taken,  and  examination  of 
the  latter,  if  any  remain,  are  important.  The  patient  often  gives  a  clear 
history. 

Prognosis. — It  is  best  to  give  a  guarded  prognosis  even  in  apparently 
favorable  cases. 

Treatment. — There  are  certain  cardinal  rules  to  follow  in  the  treat- 
ment of  toxic  gastritis:  first,  administer  fluid  to  dilute  the  poison,  and 
at  the  same  time  give  an  antidote;  empty  the  stomach  as  rapidly  as 
possible,  preferably  by  lavage;  administer  demulcents;  stimulate  the 
patient  and  give  a  cathartic  to  clear  the  poison  from  the  bowels.^ 

Though  some  advise  against  lavage  in  poisoning  from  acids  and  alkalis 
for  fear  of  perforating  the  stomach,  there  is  far  greater  danger  of  perfora- 
tion by  leaving  the  poison  in  the  organ,  with  the  additional  risk  of  cardiac 
or  respiratory  failure,  or  subsequent  damage  to  the  intestines  or  other 
viscera. 

Lavage  by  siphonage  of  the  stomach  is  indicated  in  all  cases  of  poison- 
ing. Warm  water  at  about  ioi°F.  should  be  employed,  and  the  organ 
washed  until  thoroughly  clean.  Any  bland  fluid,  such  as  tea,  coffee, 
soup,  water,  or  milk,  can  be  used  in  an  emergency  to  dilute  the  poison 
and  wash  the  stomach. 

A  gastric  siphon  can  be  improvised  from  a  fountain  syringe  by  re- 
moving the  tip  and  clip  and  rounding  the  edges  of  the  extremity;  or  from 
a  kitchen  funnel  and  rubber  tube  of  small  caliber. 

If  lavage  be  impossible,  then  give  a  pint  of  lukewarm  water  with  2 
drams  (8.0)  of  mustard  dissolved  therein,  or  warm  salt  water,  and  tickle 
the  fauces  with  the  finger  or  a  feather.  I  have  used  a  small  rubber  tube 
or  large  hat  feather  in  emergency,  pushing  them  into  the  esophagus  and 
working  them  up  and  down  to  promote  emesis. 

Apomorphin,  Xo  grain  (0.006),  by  hypodermic;  zinc  sulphate,  30 
grains  (2.0),  in  4  ounces  (30.0)  of  water;  copper  sulphate,  5  grains  (0.3), 
providing  these  latter  were  not  the  poisons  ingested;  or  syrup  of  ipecac, 
I  to  3  drams  (4.0-12.0),  can  be  employed. 

Among  useful  demulcents  are  whites  of  raw  eggs,  milk,  olive  oil,  barley- 
water,  flour  boiled  with  water,  and  gum-arabic  water.  Fats  and  oils 
should  be  avoided  in  phosphorus-poisoning.  The  subsequent  treatment  is 
of  acute  gastritis,  enteritis,  and  of  special  symptoms. 

*  Strychnine  or  camphor  oil  by  hypodermic  may  be  required. 


CATARRH    OF    THE    STOMACH  245 

Antidotes. — For  Acid  Poisoning. — Alkalis,  such  as  calcined  magnesia; 
powdered  chalk  in  water;  sodium  carbonate  (washing  soda),  dilute; 
potassium  carbonate;  sodium  or  magnesium  sulphate,  ^i  ounce  (16.0), 
in  water;  Carlsbad  salts;  soapsuds  in  water.  Soda  bicarbonate,  i  ounce 
(16.0),  or,  if  nothing  else  is  at  hand,  plaster  scraped  from  the  wall,  dissolved 
in  water,  8  ounces  (250  c.c),  can  be  employed. 

For  Carbolic  Acid. — Alcohol  (95  per  cent.),  i  to  3  ounces  (32.0-96.0); 
raw  whiskey  or  brandy,  or  liquor  with  a  large  percentage  of  alcohol. 
The  alkalis  can  be  used  subsequently  or  alone  if  alcohol  or  liquors  are  not 
obtainable. 

For  Caustic  Alkalis. — Dilute  acids,  such  as  dilute  vinegar  or  lemon 
juice;  tartar  or  citric  acid. 

For  Tartar  Emetic  and  Antimony  and  Its  Compounds. — Tannic  acid 
or  strong  tea. 

For  Arsenic  and  Its  Compounds.—  Tincture  of  perchlorid  of  iron,  i^ 
ounces  (48.0)  in  a  wineglass  of  water,  add  H  ounce  (16.0)  sodium  carbonate 
(washing  soda)  in  half-tumbler  of  water,  mix,  and  administer.  This 
renders  insoluble  about  5  grains  (0.3)  of  arsenic.  Repeat  dose,  or  give 
dialyzed  iron,  tablespoonful  doses. 

For  Copper  Salts. — Potassium  ferrocyanid,  i  dram  (4.0)  to  4  ounces 
(125  c.c.)  of  water,  forms  insoluble  copper  cyanid. 

For  lodin,  lodids,  and  Iodoform. — Starch  solution  in  cold  water; 
sodium  bicarbonate;  lead  acetate,  2  drams  (8.0)  in  4  ounces  (125  c.c.) 
of  water. 

For  Lead  and  Its  Salts. — Magnesium  or  sodium  sulphate,  i  ounce  or 
more,  or  dilute  sulphuric  acid,  30  minims  (2.0),  in  water. 

For  Mercury  and  Its  Salts  {Corrosive  Sublimate,  etc.). — White  of  raw 
egg;  milk;  form  albuminate. 

.  For  Silver  Nitrate. — Salt  solution,  teaspoon  of  salt  in  water,  4  ounces 
(125.0). 

For  Zinc  Salts. — Sodium  or  potassium  carbonate;  tannic  acid;  tea; 
white  of  egg;  milk. 

For  Phosphorus  (Rat  Paste,  Matches). — Copper  sulphate,  3  to  5  grains 
(0.2-0.3),  i^  4  ounces  (125  c.c.)  of  water,  a  number  of  doses;  forms  in- 
soluble phosphid  of  copper  and  acts  as  an  emetic;  old  French  turpentine. 
Avoid  oils,  fats,  milk,  and  yolks  of  eggs.  Avoid  American  or  German 
turpentine. 

For  Alcohol. — Ammonium  carbonate,  3  grains  (0.2),  in  water. 

The  stomach  should  receive  rest  after  immediate  treatment.  Pain 
may  be  relieved  by  local  heat,  or  codein  or  morphin,  }4  to  ^i  grain  (0.008- 
0.016),  hypodermically.  Large  doses  of  bismuth  subnitrate  may  be  given 
if  the  bowels  continue  irritable.  Retention,  or  suppression  of  urine  must 
be  watched  for.  For  the  former  catheterize;  in  the  latter  case,  entero- 
clysis,  with  hot  normal  salt  solution  at  115°  to  i2o°F.  Hypodermoclysis 
and  proctoclysis  are  also  useful.  Stenosis  of  the  esophagus  may  be  dilated 
if  possible;  if  stenosis  of  the  pylorus,  appropriate  treatment  as  for  gastric 
dilatation  temporarily,  and  then  subsequent  operation.  If  atrophy  of  the 
gastric  mucosa  result,  the  treatment  is  for  achylia  gastrica.     For  perfora- 


246  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

tive  peritonitis  operation  is  indicated.     For  uremic  poisoning  from  bi- 
chloride, section  of  the  kidney  capsules  has  been  advised. 

PHLEGMONOUS  GASTRITIS 

{Synonyms. — Suppurative    Inflammation    of    the    Stomach;    Gastritis    Phlegmonosa; 
Abscess   of  the   Stomach.) 

This  is  a  rare  disease  and  usually  runs  an  acute  course,  though  oc- 
casionally subacute.  The  process  begins  in  the  submucosa  and  some- 
times extends  to  the  muscular  coat,  and  at  times  to  the  mucous  or  serous 
coats.  It  is  more  frequent  in  men.  It  is  primary  or  idiopathic,  due  to 
some    microorganism,    especially    the  streptococcus,   probably  entering 


Fig.  180. — Phlegmonous  gastritis:  i,  Gastric  mucosa  infiltrated  with  pus-cells 
in  the  interglandular  tissue;  2,  submucosa  thickened  and  infiltrated;. 3,  purulent  col- 
lection oozing  out  on  section;  4,  fat  tissue.  (From  Bassler's  "Diseases  of  the  Stomach 
and  Upper  Alimentary  Tract."     Copyright,  1910,  by  F.  A.  Davis  Company.) 

through  some  solution  of  continuity  in  the  mucous  membrane,  such  as 
a  gastric  ulcer  or  the  erosions  of  achlorhydria  hemorrhagica  gastrica. 
Pyorrhea  alveolaris  or  the  colon  bacillus  may  be  responsible  in  some  cases. 
It  may  be  secondary  (metastatic),  due  to  pyemia,  puerperal  infection,  or 
the  exanthemata. 

Errors  in  diet,  alcoholic  excess,  trauma,  etc.,  have  been  given  as  causes, 
but  probably  only  are  contributory  by  depressing  the  system.  Trauma- 
tism might  cause  damage  to  the  mucosa  and  render  infection  more 
easy. 

Schnarwyler^  has  tabulated  83  cases,  Robinson^  reports  8  additional 
cases  and  Baird^  has  contributed  more  recently  on  this  subject. 

1  Archiv  f.  Verdaurgetev  Bull.,  1906,  xii. 
^Journ.  A.  M.  A.,  Dec.  26,  1909,  p.  2143. 
^Amer.  Jour.  Med.  Sci.,  Nov.,  1911,  p.  6488. 


CATARRH  OF  THE  STOMACH  247 

Age. — Cases  have  been  reported  from  ten  years  of  age  to  eighty-five. 
It  is  probably  most  frequent  in  early  adult  and  middle  life. 

There  are  two  forms  met  with:  a  diffuse  purulent  infiltration  and  a 
circumscribed  abscess. 

Morbid  Anatomy. — In  the  diffuse  type  a  large  area  of  the  submucosa 
is  frequently  involved.  It  is  thickened,  infiltrated  with  pus,  and  multiple 
small  abscesses  are  often  present  (Fig.  i8o).  The  pyloric  end  is  more 
frequently  attacked.  The  muscular  wall  is  often  involved  or  the  pus*  may 
burrow  through  to  the  peritoneum.  The  mucosa  is  usually  also  affected 
and  is  swollen,  and  there  is  granular  degeneration  of  the  gland  cells. 
Perforation  of  the  mucosa  may  occur. 

In  the  abscess  type  there  is  generally  a  single  circumscribed  abscess 
of  variable  size,  starting  in  the  submucosa  and  involving  the  muscular 
layer.  The  mucosa  and  serosa  are  often  involved.  It  may  terminate 
favorably  by  perforating  into  the  stomach  (a  rare  event)  or  perforate 
into  the  peritoneal  cavity. 

S3miptoms. — The  patient  may  have  for  a  brief  period  a  few  dyspeptic 
symptoms,  such  as  loss  of  appetite,  thirst,  and  some  burning  in  the 
stomach,  but  these  are  usually  absent. 

The  attack  is  generally  of  an  acute  fulminating  type:  Severe  pain 
or  burning  in  the  gastric  region,  a  rapid  rise  of  temperature  to  103°  to 
io5°F.,  with  slight  intermissions;  frequently  chills;  often  vomiting  of 
mucus,  bile,  and  food  remnants,  but  no  pus,  unless  the  abscess  breaks 
into  the  stomach,  which  is  a  rare  event.  The  area  over  the  stomach 
is  very  sensitive  to  pressure  and  there  is  some  tympanites.  There  is 
constipation  or,  more  usually,  diarrhea.  The  pulse  is  rapid  and  feeble, 
occasionally  there  is  jaundice. 

The  patient  presents  all  the  aspects  of  a  severe  infection,  with  delirium 
and  coma  preceding  death.  The  blood  examination  shows  leukocytosis 
with  increase  in  the  polynuclears.  There  is  muscular  rigidity,  in  the 
upper  quadrant  of  the  abdomen,  of  the  recti  muscles,  due  to  peritoneal 
irritation,  even  before  perforation  occurs.  This  is  a  valuable  sign.  With 
general  peritonitis  we  have  the  usual  symptoms — pain,  distention,  general 
tenderness  on  pressure,  etc. 

With  a  circumscribed  abscess  the  tenderness  is  more  localized,  the 
symptoms  not  so  severe,  and  the  duration  longer.  Percussion  and 
palpation  may  locate  the  process  if  localized. 

Duration. — Three  or  four  days,  rarely  one  to  two  weeks. 

Diagnosis. — The  temperature,  chills,  fulminating  character,  leuko- 
cytosis, and  early  recognition  of  muscular  rigidity  — all  point  to  an  acute 
suppurative  process.  Abscess  of  the  liver  and  subphrenic  abscess  are 
not  of  such  acute  type.  Acute  cholecystitis  and  acute  pancreatitis  are 
more  apt  to  be  confounded  with  abscess  of  the  stomach. 

With  acute  pancreatitis  the  temperature  at  first  may  be  low,  tym- 
panites is  earlier  and  more  marked,  and  there  are  circumscribed  tender- 
ness in  the  course  of  the  pancreas^  and  tender  spots  throughout  the  ab- 
domen (Fitz).  Hemorrhages  from  the  mucous  membranes  and  subcu- 
taneously  occur  and  there  is  jaundice.     Constipation  is  usual;  also  the 

^  Tenderness  at  Kobwin's  point  is  present. 


248  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

symptoms  may  resemble  intestinal  obstruction.  Abscess  of  the  pancreas 
is  slower  in  its  course  and  there  is  a  longer  history. 

Acute  cholecystitis  is  a  much  more  frequent  condition  than  phleg- 
monous gastritis.  The  gall-bladder  can  at  times  be  palpated,  is  tender, 
and  we  have  the  previous  history. 

Treatment. — Laparotomy  is  advised,  both  to  settle  the  diagnosis  and 
afford  relief  if  possible.  Should  this  not  be  consented  to,  then  the  ice- 
bag,  rectal  feeding,  enteroclysis  to  relieve  tympanites,  protoclysis  for  sep- 
sis and  thirst,  and  opiates  are  indicated.^ 

Bovee^  reports  a  case  with  operation  and  recovery. 

CHRONIC  GASTRITIS 

{Synonyms. — Chronic  Gastric  Catarrh;  Chronic  Dyspepsia.) 

Definition. — A  chronic  inflammation  of  the  mucous  membrane  of  the 
stomach,  with  the  production  of  mucus  and  changes  in  the  gastric  juice, 
causing  disturbances  in  the  act  of  digestion. 

Etiology. — This  disease  is  more  frequent  in  men  than  in  women.  It 
may  follow  the  acute  type,  especially  after  recurrences  of  this  condition. 
The  same  irritating  agents  that  cause  acute  gastritis  can  produce  the 
chronic  type  when  acting  for  a  long  period  of  time;  notably,  fast  eating 
with  imperfect  mastication,  overloading  the  stomach,  indigestible  food, 
highly  spiced  dishes,  cold  drinks  in  excess,  overrich  food,  excessive  use 
of  tea  or  coffee,  and  overindulgence  in  alcohol  (the  so-called  "  drunkards' 
catarrh");  excessive  use  of  tobacco,  especially  in  tobacco-chewers  and 
those  who  indulge  in  dry  smoking  (chewing  the  cigar-butt),  an  unhealthy 
condition  of  the  mouth  or  teeth,  and  swallowing  the  products  of  decom- 
position.    Habitual  use  of  drugs  may  be  a  cause. 

Discharges  from  the  nose  or  ear  through  the  Eustachian  tube,  which 
are  then  swallowed,  have  been  factors  in  several  cases  that  I  have  ob- 
served. Thrush  may  cause  mold  in  the  stomach.  Chronic  gastritis 
may  be  secondary  to  the  acute  infectious  diseases,  such  as  typhoid  fever. 
It  is  frequently  associated  with  cancer  of  the  stomach  and  is  often  present 
in  the  atonic  type  of  dilatation  of  the  stomach. 

It  may  be  secondary  to  cirrhosis  of  the  liver,  pulmonary  or  cardiac 
disease,  and  chronic  nephritis  and  syphilis.  Among  constitutional 
causes  are  gout,  diabetes,  leukemia,  and  severe  anemia. 

Classification. — Chronic  catarrhal  gastritis  may  be  classified  as  follows: 

1.  Acid  gastritis  (gastritis  hyperpeptica,  hypersthenic  gastritis),  or 
acid  catarrh  of  the  stomach,  first  described  by  Boas. 

This  is  considered  on  the  borderline  and  to  be  the  initial  stage  of 
chronic  gastritis.  There  is  an  increase  in  the  hydrochloric  acid  to  a 
variable  degree,  at  times  only  slight,  and  Boas  believes  this  occasionally 
occurs  in  the  early  stages  of  chronic  gastritis.  There  is  also  the  presence 
of  mucus. 

2.  Chronic  catarrhal  gastritis,  under  which  is  described  mucous  gas- 
tritis (Ewald),  which  is  merely  a  severe  type  with  great  secretion  of 
mucus. 

^  Strychnine  and  camphor  by  hypodermic  may  be'  required  as  stimulants. 
-  Amer.  Jour.  Med.  Sci.,  May,  1908. 


CATARRH  OF  THE  STOMACH  249 

We  must  remember  that  occasionally  from  a  long-continued  chronic 
gastritis,  other  conditions  may  arise. 

(a)  There  may  be  a  great  thickening  of  the  mucosa  (hyperplasia), 
so  as  to  produce  thick  folds,  the  so-called  etat  mamelonne,  and  this, 
combined  with  swelling  of  the  mucosa,  causes  benign  stenosis  of  the  py- 
lorus; or  sometimes  wart-like  excrescences  (gastritis  polyposa)  develop, 
which,  if  situated  at  the  pylorus,  can  produce  partial  obstruction — a 
benign  stenosis,  with  dilatation  of  the  stomach;  or  a  proliferation  of 
interstitial  tissue  occurs  and  muscular  hypertrophy,  with  resulting 
hypertrophic  stenosis  of  the  pylorus. 

Chronic  gastritis  may,  therefore,  produce  and  have  associated  with 
it  benign  pyloric  stenosis  and  dilatation  of  the  stomach. 

(b)  On  the  other  hand,  a  degeneration  or  atrophy  of  the  muscular 
fibers  due  to  hyperplasia  of  the  connective  tissues  may  cause  atony,  and 
atonic  dilatation  of  the  stomach  may  result,  and  these  conditions  will 
improve  with  the  improvement  of  the  gastritis. 

They  only  occur  in  the  more  advanced  cases.  In  the  patients  whom 
we  are  called  upon  to  treat,  the  stomach  is  usually  of  normal  size,  non- 
atonic,  and  with  normal  or  slightly  diminished  motor  functions. 

3.  Atrophic  gastritis  (Anadenia  ventriculi,  Ewald),  an  atrophy  of  the 
mucous  lining  of  the  stomach,  can  result  from  chronic  gastritis.  Of  these, 
there  are  two  forms: 

(a)  Phthisis  ventriculi,  a  thinning  of  the  coats  of  the  organ,  which 
may  remain  of  normal  size  or  be  increased  in  size. 

(b)  Cirrhosis,  or  sclerosis  ventriculi,  an  enormous  thickening  of  the 
muscular  coat  and  a  great  reduction  in  the  volume  of  the  stomach. 

Atrophic  gastritis  is  described  under  Achylia  gastrica. 

Morbid  Anatomy  of  Chronic  Catarrhal  Gastritis. — The  mucous  mem- 
brane is  yellowish-gray  or  slate-gray  in  color,  and  in  secondary  catarrhal 
conditions  produced  by  congestion  may,  in  some  parts,  be  intensely  red. 
It  is  swollen,  thickened,  and  covered  with  a  closely  adherent  tenacious 
mucus,  which  is  usually  cloudy  and  gray  in  color,  due  to  various  cells, 
epithelia,  and  leukocytes,  and  occasionally  it  is  tinged  with  blood.  En- 
larged veins,  patches  of  ecchymosis,  and  small  hemorrhagic  erosions  may 
be  present.  The  mucosa  in  some  instances  forms  papillary  projections 
(etat  mamelonne). 

The  pyloric  portion  is  usually  involved,  tliough  the  inflammation  may 
extend  over  the  entire  mucosa.  The  submucosa  and  muscular  coats  are 
at  times  hypertrophied  or  atrophied. 

Microscopically  the  following  conditions  appear:  The  glands  are 
enlarged,  sacculated,  and  dilated  in  cyst-like  forms,  the  tubuli  in  many 
places  being  atypic  and  branching  like  the  fingers  of  a  glove;  the  gland- 
cells  are  cloudy,  granular,  and  in  a  condition  of  fatty  degeneration,  and 
the  principal  and  parietal  cells  cannot  be  differentiated.  Abundant 
small  cell  infiltration  presses  the  glands  apart,  being  especially  marked 
toward  the  surface  of  the  mucosa.  Extensions  of  connective  tissue  may 
be  seen  passing  from  the  mucosa  between  the  glands.  The  mouths  of 
the  glands  are  at  times  filled  with  mucus  which  projects  against  the  lumen. 
Mucoid  transformation  of  the  cells  of  the  tubuli  is  a  striking  feature  and 


250  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

may  extend  to  the  fundus  of  the  glands  and  cells.  Mucoid  degeneration 
may  replace  the  principal  and  parietal  cells. 

The  mucus  fills  part  of  these  cells,  or  may  crowd  the  protoplasm  and 
nucleus  against  the  base,  or  rupture  the  cell-membrane  and  escape  into 
the  duct  of  the  gland.     The  pyloric  region  is  usually  thus  affected. 

After  a  long  period  the  inflammatory  process  may  lead  to  a  total 
destruction  of  the  glandular  layer,  or  atrophy  of  the  mucous  membrane 
of  the  stomach — Anadenia  ventriculi  (Ewald).  Of  this  there  are  two 
forms,  as  heretofore  noted: 

(a)  Phthisis  ventriculi,  atrophy  of  the  stomach,  or  Anadenia  ventriculi 
is  a  thinning  of  the  coat  of  the  stomach,  with  a  retention  of,  or  usually 
an  increase  in  the  size  of  the  organ  (dilatation).  There  are  fatty  de- 
generation and  destruction  of  the  glands,  the  process  progressing  from 
the  surface  of  the  stomach  inwardly.  In  the  early  stage  no  glands  are 
found,  but  glandular  cysts  are  present  near  the  submucosa.  Later  these 
disappear  and  the  mucous  membrane  consists  chiefly  of  round  cells.  The 
submucosa  is  changed  and  the  muscular  layer  is  thinner. 

(b)  In  cirrhosis,  or  sclerosis  ventriculi,  the  stomach  coats  are  thickened 
and  there  is  a  great  reduction  in  the  volume  of  the  organ;  in  some  cases 
it  is  no  larger  than  a  pear  and  the  walls  may  be  2  to  3  cm.  in  thickness, 
the  greatest  increase  being  in  the  submucosa,  where  the  process  starts. 
The  inflammatory  process  causes  the  formation  of  fibrous  tissue,  which 
progresses  from  the  submucosa  to  the  surface,  spreading  around  the 
glands,  constricting  them,  and  finally  replaces  them  with  fibrous  tissue. 
The  hypertrophy  extends  to  the  muscular  layer. 

This  condition  may  coexist  in  the  cecum  and  colon  and  so  be  difficult 
to  distinguish  from  diffuse  carcinoma.  Proliferative  peritonitis  with 
periphepatitis  and  ascites  are  at  times  associated. 

Atrophy  of  the  gastric  mucosa  is  described  under  Achylia  gastrica. 

Symptoms  of  Chronic  Gastritis. — These  develop  slowly;  the  appetite 
diminishes  or  is  irregular  or  easily  satiated.  There  is  a  feeling  of  fulness 
or  pressure  in  the  gastric  region  after  eating.  Occasionally  heartburn 
or  cardialgia  in  the  epigastrium  or  precordial  region  or  behind  the  sternum 
occurs,  generally  at  the  height  of  digestion;  while  with  hyperchlorhydria 
it  is  present  late  or  on  an  empty  stomach.  Discomfort  or  pain  on  pressure 
over  the  stomach  is  present.  Belching  of  gas  is  the  most  frequent  symptom 
and  it  is  usually  odorless;  water-brash  (pyrosis),  a  bitter  or  a  tasteless^ 
fluid,  may  be  brought  up  into  the  mouth  (regurgitation);  the  stomach  and 
intestines  are  often  markedly  distended  with  gas.  Nausea  is  frequently 
present  and  occasionally  vomiting. 

When  the  latter  occurs,  it  is  frequent  in  the  morning,  when  the  stomach 
is  empty,  and  consists  chiefly  of  slimy  mucus,  and  sometimes  of  partly 
digested  food  of  the  previous  day  with  mucus.  It  may  take  place  after 
breakfast.  There  is  a  sour,  bad,  or  salty  taste  in  the  mouth.  The  patient 
in  some  cases  complains  of  palpitation  and  shortness  of  breath  (dyspeptic 
asthma  or,  more  correctly,  dyspnea).  The  pulse  is  small  and  sometimes 
slow.  There  are  fulness  in  the  head,  insomnia,  lack  of  energy,  and  dis- 
taste for  work.  Dizziness  may  be  present.  Sensation  of  fear,  depres- 
sion,   melancholia,    or   hypochondriasis   occur   in   some   patients.     The 


CATARRH  OF  THE  STOMACH  25 1 

tongue  is  usually  covered  with  a  thick  gray  moist  fur,  though  not  always 
so,  and  it  cannot  be  said  to  be  characteristic.  The  margins  are  at  times 
indented.  Odor  of  the  breath  is  present  when  there  is  disease  of  the  mouth 
or  teeth  or  atony  of  the  stomach  with  fermentation.  Headache  is  quite 
common  and  a  desire  to  yawn.  There  is  at  times  the  so-called  stomach- 
cough,  doubtless  due  to  pharyngeal  irritation. 

The  patient's  appearance  may  be  quite  good  and  he  may  preserve 
his  weight.  In  severe  cases  he  looks  quite  badly,  and  shows  black  rings 
under  his  eyes,  has  cold  hands  and  feet,  and  chills  easily.  Some  even  lose 
considerable  weight  and  become  thin  and  emaciated.  In  the  severe 
types  with  nervous  symptoms,  intestinal  fermentation  or  putrefaction 
are  often  present  and  auto-intoxication  is  undoubtedly  a  factor.  The 
bowels  are,  as  a  rule,  constipated;  though  occasionally  diarrhea  or  diarrhea 
alternating  with  constipation  are  present.  Occasionally  there  may  be 
an  associated  duodentis  with  jaundice. 

Physical  Examination. — Inspection. — The  gastric  region  appears 
bloated. 

Percussion. — ^Tympanites  is  present,  but  the  stomach  is  usually  in  the 
normal  position. 

Palpation. — The  gastric  region  is  in  some  sensitive  to  pressure;  ten- 
derness is  rather  diffuse.     No  real  pain  or  sense  of  resistance. 

Splashing  sound  can  be  produced  if  liquid  and  gas  are  present.  It  is 
only  abnormal  if  found  at  a  time  when  the  stomach  should  be  empty.  It 
would  then  show  atony.  If  found  in  an  abnormal  position  (low),  it  is  an 
evidence  of  dilatation  or  ptosis.  With  movable  kidney  ptosis  can  be 
diagnosed. 

Urine  is  scanty;  contains  phosphatic  and  urate  deposits.  Indican 
may  be  present.     Specific  gravity  is  increased. 

Diagnosis. — The  presence  of  gastric  mucus  in  the  stomach  contents 
is  the  chief  diagnostic  point  in  chronic  gastritis,  so  that  examination  of 
the  vomitus  or,  preferably,  of  the  gastric  contents  after  a  test-breakfast  is 
imperative.  The  diagnosis  should  not  be  made  from  clinical  symptoms 
alone. 

Gastric  Contents. — One  hour  after  Ewald's  test-breakfast  or  the  one 
I  employ — 2  slices  (60  grams)  of  bread  without  butter  and  350-400  c.c. 
of  water  the — contents  of  the  stomach  are  withdrawn.  The  following  are 
the  conditions  found  present: 

Total  acidity  is  diminished;  free  hydrochloric  acid  is  markedly  les- 
sened or  is  small  in  amount  or  absent;  pepsin  and  rennet  are  present,  but 
diminished;  erythrodextrin  present  in  small  quantities;  a  chroodextrin  and 
sugar  abundant;  quantity  of  gastric  contents  frequently  normal  (under 
100  c.c.)  or  may  be  slightly  more  (100  to  150  c.c),  which  last  would  show 
some  motor  insufficiency. 

The  pieces  of  roll  are  not  as  fine  as  normally,  but  larger  and  coarser. 
Mucus  is  usually  intimately  mixed  with  the  food  remnants  and  is  adherent 
to  the  morsels  of  food.  The  stomach-contents  are  thick,  tough,  and 
sticky,  and  difficult  to  filter.  A  glass  rod  dipped  into  them  and  lifted 
up  will  draw  up  strings  of  mucus  with  it.  Acetic  acid  added  to  the  filtrate 
produces  turbidity. 


252  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

Mucus  that  has  been  swallowed  is  never  mixed  with  the  food  remnants, 
but  floats  as  isolated  balls  on  the  surface. 

Mucus  in  some  cases  is  in  large  amount,  while  there  may  be  very  little 
in  others.  In  the  latter  event,  lavage  of  the  empty  stomach  will  determine 
its  presence,  in  shreds  or  flakes. 

In  the  fasting  condition  there  are  often  only  a  few  cubic  centimeters 
of  turbid  liquid  in  the  stomach,  consisting  chiefly  of  mucus  of  an  alkaline, 
neutral,  or  slightly  acid  reaction.  If  no  contents  can  be  thus  secured, 
lavage  again  will  show  the  mucus. 

The  vomitus  shows  the  same  characteristics  already  described,  but 
the  examination  by  the  test-breakfast  is  more  accurate. 

Microscopically. — Mucus,  round  cells,  and  epithelial  cells  are  found  to 
be  present.  In  doubtful  cases  the  microscope  may  differentiate  the  types 
of  mucus.  If  squamous  epithelia  be  mixed  with  it,  it  probably  comes 
from  the  mouth  or  pharynx;  if  pigmented  alveolar  epithelia,  probably 
from  the  air-passages.  Columnar  epithelia  mixed  with  mucus  show  it 
is  gastric. 

With  acid  gastritis  we  find  the  total  acidity  and  free  hydrochloric  acid 
slightly  increased  and  the  presence  of  mucus.  I  had  recently  a  case  in 
which  the  total  acidity  averaged  90+  and  free  hydrochloric  acid  yo-f-, 
with  a  large  amount  of  mucus. 

The  so-called  cases  of  mucous  gastritis  merely  contain  an  excessive 
amount  of  mucus,  with  little  or  no  hydrochloric  acid. 

With  atrophic  gastritis  there  is  absence  of  hydrochloric  acid,  absence 
of  pepsin,  and  absence  of  rennet,  as  described  under  Achylia  gastrica. 

If  dilatation  be  present,  we  have  the  physical  signs  of  such. 

Einhorn  finds  small  shreds  of  the  mucosa  present  in  the  wash-water 
of  some  cases  of  chronic  gastritis,  due,  as  he  believes,  to  erosions. 

Motor  function  may  be  normal  or  slightly  diminished,  so  that  the  ingesta 
escape  before  fermentation  can  occur.  This  is  the  usual  course  in  the 
ordinary  type  of  case. 

In  some  cases  with  hypertrophy  the  motor  function  may  be  increased. 
If  atony  or  dilatation  is  present,  there  are  motor  insuflSciency  and 
fermentation. 

In  those  with  excessive  mucus  production,  the  action  of  the  saliva 
and  gastric  juice  is  interfered  with,  and,  though  the  motor  function  is 
good,  the  ingesta  passes  into  the  intestines  with  little  change,  and  intestinal 
fermentation  or  putrefaction  results. 

Absorption. — This  depends  on  the  severity  of  the  case;  in  milder  cases, 
with  the  iodid  of  potassium  test,  it  seems,  normal;  in  severe  cases  it  is 
interfered  with. 

Course. — The  duration  of  chronic  gastritis  is  long,  often  extending 
over  many  years.  Marked  improvement  may  take  place,  but  relapses 
are  apt  to  occur  from  indiscretions.  Milder  cases  can  be  permanently 
cured. 

Differential  Diagnosis. — Chronic  Gastritis. — No  severe  pain;  no  cir- 
cumscribed spot  painful  to  pressure;  no  hematemesis;  no  cachexia;  no 
marked  emaciation,  except  in  severe  cases  of  long  duration;  free  HCl 
diminished  or  absent;  gastric  mucus  present;  slow  course. 


CATARRH  OF  THE  STOMACH  253 

Ulcer  of  the  Stomach. — Hydrochlorhydria  present,  but  not  invariably 
so;  severe  pain  in  the  epigastrium,  with  intervals  free  from  pain  when  the 
stomach  is  empty;  local  tenderness  which  is  circumscribed;  dorsal  pain, 
hematemesis,  or  occult  blood  in  the  stool  or  gastric  contents;  microscopic 
pus;  no  mucus;  patient  has  appearance  of  suffering;  no  true  cachexia. 
X-ray  findings  of  such. 

Cancer. — Age,  usually  over  forty-five;  rapid  course;  free  HCl  usually 
markedly  diminished  or  absent;  lactic  acid  present;  mucus  sometimes 
present;  pain  generally  continuous,  but  not  as  acute  as  in  ulcer;  Boas- 
Oppler  bacillus;  cachexia;  tumor  on  physical  examination;  small  amount 
of  blood  or  occult  blood  present  in  gastric  contents;  microscopic  pus; 
blood  or  occult  blood  in  the  stool;  hematemesis  much  less  than  ulcer; 
foul  odor  to  vomitus  at  times  present.      X-ray  findings  of  such. 

Achylia  Gastrica. — Slow  course;  scarcely  any  gastric  juice;  acidity 
very  low  (2-f  to  4-j-);  absence  of  HCl;  absence  of  pepsin;  absence  of 
rennet;  usually  no  mucus;  no  lactic  acid.  In  the  early  stage  (transi- 
tional) Riegel  holds  that  mucus  may  at  times  be  present. 

Achlorhydria  Haemorrhagica  Gastrica. — This  is  frequently  a  reflex  from 
a  diseased  appendix  or  gall-bladder.  Large  numbers  of  bacteria,  most 
frequently  streptococci  or  colon  bacilli,  are  present  in  the  gastric  contents. 
Free  hydrochloric  acid  is  absent.  Occult  blood  from  erosions  is  present 
in  the  gastric  contents.  The  amount  recovered  after  the  test-breakfast 
is  usually  less  than  that  ingested,  and  the  bread  is  in  a  coarse  state  of 
division,  practically  as  when  swallowed,  and  thin  mucus  is  incorporated 
with  it.  The  contents  when  aspirated  vary  from  a  yellow  tinge  to  a  light 
orange.  Total  acidity  is  6-1-  to  8+-  Pain  occurs  in  about  one-third 
the  cases  directly  after  food,  but  may  be  present  at  other  times.  Vomiting 
of  a  sour  taste  occurs  in  about  half  the  cases  and  nausea  is  frequent.  These 
patients  generally  have  periods  of  depression  alternating  with  nervous 
excitement.  Constipation  is  usual.  Pylorospasm  usually  is  present 
which,  together  with  the  erosions,  often  accounts  for  the  pain.  The 
condition  is  in  most  cases  a  reflex  disturbance  of  gastric  secretion 
(absence  of  hydrochloric  acid)  with  a  secondary  invasion  of  the  stomach 
by  microorganisms  and  ultimately  erosions  of  the  mucosa.  It  has 
also  been  found  secondary  to  infectious  diseases  and  other  conditions, 
and  cure  of  the  primary  disease  has  usually  resulted  in  the  cure  of  the 
gastric  lesion. 

Gastric  Neuroses. — Symptoms  not  uniform;  character  of  food  makes 
little  difference;  indigestible  food  may  be  well  borne  and  digestible  food 
may  cause  symptoms;  no  gastric  mucus;  HCl  may  be  diminished  or  in 
some  cases  normal  or  increased,  and  the  gastric  findings  often  vary  at 
different  times  in  the  same  patient.  Subjective  symptoms  are  sometimes 
similar  to  chronic  gastritis,  but  they  disappear  and  reappear  abruptly. 

Prognosis.—  Some  cases  can  be  cured ;  many  improved.  Relapses  may 
occur.     The  affection  is  frequently  a  tedious  one. 

Treatment. — This  may  be  divided  into:  (i)  Prophylaxis.  (2) 
Hygiene.  (3)  Local  treatment  of  the  stomach.  (4)  Diet.  (5)  Mineral 
springs.     (6)  Medication. 

Acid  Gastritis. — The  borderline  cases,  ctcid  gastritis,  should  receive  the 


254  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

treatment  of  hyperchlorhydria;  also  occasional  lavage  to  remove  mucus, 
say,  twice  a  week,  is  advisable.  In  a  recent  case  I  have  employed  it 
daily,  using  several  ounces  of  milk  of  magnesia  (Phillips)  to  the  quart  of 
water. 

Extract  of  belladonna,  H  grain  or  tinct.  belladonna  lo  gtts.  (0.022), 
t.i.d.  before  meals,  and  magnesia  usta  and  soda  bicarbonate,  da,  10 
grains  (0.6),  combined  with  resorcin  resub.,  5  grains  (0.3),  in  water,  or  the 
magnesia  and  soda  5ss  doses,  or  soda  bicarb.  5ss  t.i.d.  alone,  an  hour 
after  meals  are  excellent.  Milk  of  magnesia,  i  to  2  drams  (4.0-8.0),  is 
also  of  value. 

1.  Prophylaxis. — Unquestionably,  repeated  attacks  of  mild  so-called 
acute  dyspepsia  (acute  gastritis)  may  ultimately  lead  to  the  development 
of  chronic  gastritis.  The  causes  of  both  conditions  are  practically  the 
same.  The  patient,  therefore,  should  masticate  thoroughly,  avoid  bolt- 
ing the  food,  overindulgence  in  alcohol,  tobacco,  very  hot  or  very  cold 
food  and  drink,  indigestible  food,  etc.  He  shoUld  rest  for  fifteen  to  thirty 
minutes  after  meals  before  returning  to  business.  The  mouth  and  teeth 
should  be  kept  in  good  condition ;  and  if  there  are  aural  or  nasal  discharges 
escaping  into  the  mouth,  or  tonsillar  or  pharyngeal  inflammation,  treat- 
ment should  be  instituted.  " 

Cardiac  disease  should  be  treated  with  cardiac  stimulants,  especially 
if  there  is  failing  compensation;  and  diseases  of  the  liver  and  kidney  should 
receive  appropriate  diet  and  treatment,  so  as  to  lessen  the  chances  of 
secondary  gastritis. 

2.  Hygiene. — Slow  eating,  with  subsequent  rest;  exercise,  preferably 
in  the  open  air,  driving,  golf,  rowing,  walking,  and  horseback — all  of 
which  should  be  carried  out  in  a  leisurely  manner  and  not  overdone,  so 
as  to  exhaust  the  patient,  are  useful.  Moderate  gymnastic  exercises 
five  or  ten  minutes  daily,  as  with  an  exerciser,  with  open  windows,  are  of 
value. 

Avoid  badly  ventilated  rooms  and  sleep  with  the  windows  open. 

Cold  salt-water  sponging  morning  and  night,  followed  by  friction  with 
a  rough  towel,  is  of  service. 

If  the  patient  is  excessively  nervous,  change  of  climate  may  be 
necessary. 

3.  Local  Treatment. — The  removal  of  the  mucus  is  of  importance. 
This  can  be  done  by  two  methods:  By  administering  alkaline  remedies 
that  will  dissolve  the  mucus  and  by  lavage. 

In  mild  cases  lavage  is  not  always  necessary,  and  the  use  of  alkalis 
is  of  service. 

They  should  be  administered  about  an  hour  before  breakfast  and,  if 
necessary,  also  before  luncheon  and  dinner.  For  example,  in  6  to  8 
ounces  (200  to  250  c.c.)  of  hot  water,  soda  bicarbonate,  30  grains  to  i 
dram  (2.0-4.0),  or  lime-water,  K  ounce  (16.0),  or  milk  of  magnesia 
(Phillips),  I  to  2  drams  (4.0  to  8.0). 

Magnesia  usta,  30  grains  to  i  dram  (2.0  to  4.0),  is  of  use,  alone  or 
combined  with  equal  quantities  of  soda  bicarbonate. 

Penzoldt  has  demonstrated  that  mucus  will  adhere  to  bismuth.  The 
late  A.  Rose  suggested  a  tablet  consisting  of  10  grains  (0.6)  magnesia 


CATARRH    OF    THE    STOMACH  255 

usta  and  10  grains  (0.6)  bismuth  subnitrate,  to  be  chewed  with  a  full  glass 
of  water  one  hour  before  meals;  or  two  tablets,  if  required. 

The  magnesia  usta,  milk  of  magnesia,  or  soda  bicarbonate  are  especially 
useful. 

Lavage. — When  the  mucous  secretion  is  more  marked,  lavage  should 
be  substituted;  or  if  a  mild  case  does  not  improve  by  the  above  method. 
This  should  be  employed  on  the  empty  stomach  before  breakfast,  so  as 
to  aid  subsequent  digestion.  An  alkali  should  preferably  be  added  to 
the  fluid  to  dissolve  the  mucus.  The  stomach  should  be  washed  with  the 
patient  both  sitting  and  lying  down  and  turning  on  the  sides,  to  remove  all 
mucus  possible,  and  washed  until  the  outflow  is  clear. 

The  following  are  excellent:  Milk  of  magnesia  (Phillips),  i  to  2 
ounces  (30.0  to  60.0)  to  the  quart  (liter);  or  lime-water  the  same  quantity; 
or  soda  bicarbonate,  i  to  2  drams  (4.0  to  8.0);  or  magnesia  usta,  i  to  4 
drams  (4.0  to  8.0) — 'all  to  the  quart  (liter). 

Normal  saline  solution — i  dram  (4.0)  salt  to  water  i  pint  (500  c.c.) — 
or  boric  acid,  i  dram  (4.0)  to  the  quart  (liter),  may  be  employed. 

I  use  normal  saline  solution  combined,  preferably,  with  milk  of  mag- 
nesia or  magnesia  usta. 

Fleiner  mixes  2  parts  sodium  chlorid  and  i  part  soda  bicarbonate  and 
employs  i  dram  (4.0)  to  2  to  3  quarts  (liters)  of  water. 

Frequency  of  Lavage. — Once  a  day  before  breakfast  is  often  sufficient; 
in  some  cases  it  may  be  necessary  to  repeat  it  before  supper. 

If  there  is  dilatation  with  fermentation,  resorcin  (resub.),  10  to  20  grains 
(0.6  to  1.3),  or  the  same  quantity  of  salicylic  acid  or  sodium  salicylate;  or 
gomenol,  15  drops  to  ^i  dram  (i.o  to  2.0);  or  potassium  permanganate, 
5  grains  (0.3);  or  listerin,  glycothymolin,  or  borolyptol,  i  dram  (4.0) — 
all  to  the  quart  (liter),  can  be  employed. 

In  such  event,  I  wash  with  the  alkali  in  the  morning  to  remove  mucus, 
and  with  the  antifermentative  at  night. 

In  some  cases,  lavage  with  nitrate  of  silver  (i  :  5000  to  i :  2000)  or 
protargol  or  argyrol  (i  :  2000)  is  of  value,  used  every  two  or  three  days, 
preceded  by  warm  water  lavage,  to  first  remove  mucus.  No  saline  should 
be  used  in  the  silver  nitrate  solution.  Saline  solution  may  subsequently 
be  used  if  the  silver  cause  pain  or  irritation. 

Pepp)er,  in  place  of  this,  advocates  an  aqueous  solution  of  silver 
nitrate;  dose,  ^i  to  J^  grain  (0.008-0.016)  internally,  three  times  a  day 
for  a  short  period.     This  should  be  kept  in  a  dark  bottle. 

Electricity.— VnX&s.s  atony  with  lessened  motor  function  of  the  stomach, 
or  severe  subjective  symptoms,  with  little  mucus  are  present,  electricity 
is  of  no  practical  value. 

When  there  is  little  mucus,  it  may  aid  to  stimulate  gastric  secre- 
tion. In  such  event  the  intragastric  method  is  preferable  to  the  per- 
cutaneous. Removal  of  the  mucus  is  of  the  first  importance.  Electricity, 
however,  is  of  service  applied  to  the  abdomen  to  increase  intestinal 
peristalsis. 

Massage. — Vibratory  Massage. — The  same  holds  true  of  these  methods. 
They  are  also  of  value  over  the  intestines  to  promote  peristalsis. 


256  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Hydrotherapy. — In  sensitive  cases  hot  water  compresses  applied  to  the 
stomach  are  useful. 

-4.  Z>/e^— This  is  an  important  feature,  and  its  character  depends 
on  the  severity  of  the  symptoms.  It  is  always  preferable  to  give  four 
or  five  light  meals  than  three  full  meals  a  day.  In  severe  cases  give 
food  in  liquid  and  semiliquid  form  (mushes),  such  as  milk  or  matzoon 
with  Vichy,  kumiss,  bacillac,  lactone-buttermilk,  barley,  oatmeal,  or 
rice  soups  prepared  with  milk ;  or  chicken  soup  or  bouillon,  with  raw  egg 
beaten  up;  somatose,  plasmon,  or  tropon  can  be  added  to  the  soups. 

Later,  soft-boiled  eggs,  mashed  potatoes,  rice  gruel,  scraped  raw 
or  broiled  beef,  toast  baked  in  the  oven,  stale  bread  (white),  butter, 
cocoa,  weak  tea,  barley  gruel,  oatmeal  gruel,  hominy  and  other  cereals 
and  purees. 

The  diet  should  be  mixed,  the  albumin  somewhat  reduced;  the  car- 
bohydrates should  be  given  in  suitable  form,  avoiding  those  that  contain 
too  much  cellulose.  Peas  shovdd  be  passed  through  a  sieve  to  remove 
the  skins.  Fats,  such  as  butter  and  cream,  are  especially  necessary, 
when  there  is  loss  of  niUrition.  In  the  latter  case  I  feed  by  the  "scales," 
endeavoring  to  put  on  weight,  improve  assimilation,  and  at  the  same 
time  ameliorate  symptoms. 

The  mere  estimate  of  requisite  calories  and  feeding  by  this  method 
alone  is  of  no  value,  as  each  patient  is  a  rule  to  himself. 

For  example:  In  severe  cases,  give  at  first  liquids  and  mushes. 

8.00  A.  M.  Milk,  one  glass,  with  2  ounces  (about  125  c.c.)  of  lime- 
water,  or  peptonized  milk,  8  ounces  (about  250  c.c). 

10.30  A.  M.  Matzoon  and  Vichy  equal  parts,  in  all  6  to  8  ounces 
(200-250  c.c). 

1.30  p.  M.  Oatmeal  soup  or  chicken  soup,  with  an  egg  beaten  in, 
8  ounces  (250  c.c). 

4.00  p.  M.     Same  as  at  10.30  a.  m. 

6.30  p.  M.     Same  as  at  8.00  a.  m. 

9.30  p.  M.     Milk  and  Vichy  equal  parts,  in  all  8  ounces  (250  c.c). 

Additions  can  gradually  be  made  to  this  diet.  Milk,  however, 
does  not  agree  with  some,  and  soups  and  broths  must  be  substituted. 

The  following  diet  is  useful  in  many  cases  for  a  week  or  two,  but 
must  be  modified  to  suit  the  individual: 

Calories 
8.00  A.  M.  I  cup  cocoa  or  tea,  about  two-thirds  milk,  approximately.  100 

1  lump  of  sugar 40 

2  soft-boiled  eggs 165 

2  ounces  zwieback,  or  toast,  or  stale  white  bread  (2  slices).  150. 
}6  ounce  butter 115 

10.30  A.  M.  8  ounces  (250  c.c.)  koumiss,  matzoon,  or  milk. 168 

2  ounces  crackers  or  somatose  biscuit 150 

^  ounce  butter 115 

i.oo  p.  M.  2  ounces  of  steak,  chicken,  or  chop 70 

3  ounces  of  mashed  potatoes  or  rice 130 

2  ounces  white  bread  (stale),  or  toast,  or  zwieback 150 

I  cup  tea,  about  two-thirds  milk,  approximately 100 

Vi  ounce  butter 115 


CATARRH  OF  THE  STOMACH  257 

Calories 
4.00  A.  M.  7  ounces  (250  c.c.)  milk,  mixed  with  i  ounce  top-cream.  .    210 

1  ounce  crackers 100 

H  ounce  butter 100 

6.30  p.  M.  8  ounces  (250  c.c.)  hominy,  rice,  or  cereal  boiled  in  milk.  450 

2  scrambled  or  poached  eggs 165 

2  slices  bread  (average  about  2  ounces) 150 

y2  ounce  butter 115 

2858 

The  above  is  for  about  three  weeks,  and  the  diet  of  each  patient 
should  later  correspond,  as  nearly  as  possible,  to  the  usual  mode  of 
living. 

There  are  thipgs  which  it  is  necessary  to  forbid,  such  as  fried  food; 
meat  with  tough  fibers  or  that  is  too  old  or  too  fresh,  pork,  sausages; 
lobster,  salmon;  chicken  salad;  mayonnaise;  cucumbers,  fresh  tomatoes, 
pickles,  corn,  radishes,  raw  celery,  cabbage;  hot  breads,  brown  and 
Graham  bread;  also  fresh  bread  and  all  alcoholic  beverages,  which  last  I 
believe  do  special  harm  to  the  inflamed  mucous  membrane. 

Foods  which  disagree  should  be  interdicted.  Sugar  should  be  taken 
in  small  quantity  and  avoided  by  some.  Soda-water  and  candy  are 
forbidden;  also  hot  and  cold  arinks,  and  ice-cream.  Veal,  as  a  rule,  in 
this  country  is  interdicted,  as  it  is  often  tough. 

Salt  is  of  value,  as  it  aids  the  production  of  HCl. 

Beef,  mutton,  lamb,  chicken,  potatoes,  hominy,  rice,  oatmeal,  spinach, 
lettuce,  asparagus,  eggs,  etc.,  are  all  admissible.  Water  should  be  taken 
in  small  amounts  during  the  meal. 

Smoking. — Excessive  smoking  should  be  stopped.  It  is  chiefly 
the  tobacco  juice  from  chewing  the  cigar,  carried  by  the  saliva,  that 
damages  the  mucous  membrane  of  the  stomach;  chewing  tobacco  should 
be  forbidden. 

//  a  cigar-holder  or  cigarette-holder  be  employed,  I  can  see  no  objection 
to  two  cigars  or  four  cigarettes  a  day;  otherwise  it  should  be  interdicted. 
If  there  is  nasopharyngeal  catarrh,  smoking  should  be  stopped. 

5.  Mineral  Waters. — These  dissolve  the  gastric  mucus,  hasten  the 
emptying  of  the  stomach,  and  often  stimulate  the  mucosa.  On  account 
of  the  rest  and  regular  life  and  diet  the  springs  are  often  preferable, 
though  the  waters  may  be  taken  at  home.  The  most  useful  are  the  saline 
and  the  saline-alkaline  waters. 

(a)  Saline  Springs. — These  contain  chiefly  sodium  chlorid  and 
varying  quantities  of  carbonic  acid  gas,  and  stimulate  the  secretion 
of  hydrochloric  acid.  The  most  notable  are  Kissengen,  Homburg,  Wies- 
baden, Soden  and  Saratoga  (Congress  Spring).  Dose,  glass  of  mineral 
water  on  arising. 

(b)  Alkaline-saline  Springs. — These  contain  sulphate  of  soda,  sodium 
bicarbonate,  sodium  chlorid,  and  carbonic  acid  gas. 

The  Carlsbad  Springs  are  the  most  famous.  Marienbad  and  Saratoga 
(Hawthorne  Spring)  belong  to  this  group,  also  Glauber's  Salt  Springs  and 
Glauber's  salts. 

One  can  employ  the  imported  Carlsbad  salts  or  Glauber's  salts  and 
17 


258  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

by  adding  sodium  bicarbonate  to  Glauber's  salts  imitate  imported  waters 
more  closely. 

Wolfif's  formula  for  artificial  Carlsbad  salts: 

I^.  Sulphate  of  soda 30.0 

Sulphate  of  potassium 5.0 

Sodium  chlorid 30.0 

Carbonate  of  soda 25 .0 

Biborate  of  soda lo.c— M. 

Sig. — I  to  I  dram  (2.0-4.0)  in  warm  water  before  breakfast. 

The  Alkaline-Saline  springs  are  of  value  for  the  solution  of  large 
quantities  of  mucus  and  for  constipation.  Care  should  be  taken  not 
to  purge  the  patient  excessively,  and  nervous  cases  do  not  take  them 
especially  well. 

6.  Medication. — The  methods  described  will  often  be  sufficient,  but 
medication  is  of  service  as  an  accessory. 

Leube  was  the  first  to  recommend  the  use  of  dilute  hydrochloric 
acid  to  supplement  this  deficiency  of  the  gastric  juice.  Ewald  advised 
the  use  of  large  amounts,  40  to  60  drops,  taken  in  divided  doses  three 
times  a  day  after  meals. 

For  example:  The  entire  dose  in  a  glass  of  water  and  commenc- 
ing one-half  hour  after  meals,  a  third  of  this  being  taken  every  fifteen 
minutes. 

I  prefer  a  smaller  dose,  from  15  to  20  drops,  in  a  small  glass  of  water 
three  times  a  day  one-half  hour  after  meals,  and  taken  in  three  divided 
doses,  as  advised  by  Ewald.  This  is  impossible  to  pursue  with  some 
patients,  as  they  will  not  devote  the  time;  so  in  such  an  event  a  single 
dose  can  be  administered,  commencing  at  5  drops  and  gradually  increasing 
to  15  drops. 

The  following  is  an  excellent  prescription : 

I^.  Tinct.  nucis  vomicae 12.0  (3iij)» 

Acid,  hydrochlor.  dilut.  "I  c*    ^ 

Comp.   tinct.   cinchona/ *^     '^^  ^^^^^' 

Aq.  destil q.  s.  ad.  125.0  (3iv). — M. 

Sig. — I  to  2  drams  (4.0-8.0)  t.i.d.  in  water  one-half  hour  after  food. 

A  convenient  method  of  administering  hydrochloric  acid  is  in  the 
form  of  oxyntin.  This  can  be  given  in  5-grain  (0.3)  capsules.  Ten 
grains  of  oxyntin  represents  5  minims  of  dilute  hydrochloric  acid.  There 
is  also  a  preparation  of  oxyntin  with  nux  vomica.  A  5-grain  (0.3)  capsule 
of  this  preparation  contains  5  minims  of  the  tincture  of  nux  vomica. 
One  to  two  of  these  capsules  can  be  given  half  an  hour  to  an  hour  after 
meals.     Oxyntin  is  a  powdered  form  of  HCl  and  is  convenient. 

Pepsin  is  present  in  considerable  quantity  in  chronic  gastritis,  so  it 
is  hardly  indicated;  though  some  add  7H  to  15  grains  (0.5-1)  in  com- 
bination. Papayotin,  papain  or  papoid,  or  pancreatin,  15  to  22H  grains 
(1.0-1.5),  with  sodium  bicarbonate,  have  been  suggested;  also  the  diastase 
combinations,  wines  of  pepsin,  etc. 

The  use  of  artificial  digestants  would  tend  to  weaken  the  gastric 
functions,  and  are  not  indicated. 


CATARRH  OF  THE  STOMACH  259 

The  bitter  medicaments  such  as  stomachics,  to  stimulate  the  secretory 
function  and  appetite,  are  often  employed,  and  Riegel  believes  the 
hydrochloric  acid  acts  in  this  way.  They  should  be  used  fifteen  minutes 
before  meals  in  i  to  2  ounces  of  water.  There  has  been  considerable 
dispute  as  to  the  effect  of  bitter  tonics  on  gastric  secretion.  Pawlow  notes 
in  dogs  that  the  bitters  cause  increased  salivary  flow,  but  have  no  effect 
on  the  gastric  glands  even  when  introduced  into  the  stomach.  Others 
claim  the  bitters  depress  gastric  secretion.  Cushny  believes  their  chief 
value  is  due  to  their  mental  impression  as  they  are  an  aid  to  psycho- 
therapy. Hemmeter  has  demonstrated  the  presence  of  a  hormone  in 
the  saliva  of  dogs  which  stimulates  gastric  secretion  and  it  would  seem 
that  remedies  stimulating  the  salivary  secretion  would  thus  at  least  in- 
directly effect  gastric  secretion.     Clinically  the  stomachics  seem  useful. 

Among  such  remedies  are  tincture  aurantii  amara;  tincture  amara 
(bitter  tincture,  Squibb's);  tincture  calumba;  fluidextract  calumba; 
tincture  cardamomi;  tincture  hydrastis;  tincture  gentian  compositum; 
fluidextract  hydrastis;  fluidextract  condurango;  fluidextract  quassia. 

The  average  dose  for  this  purpose  of  any  of  these  remedies  would 
be  from  15  to  20  drops;  quassia,  in  5  to  10  drops;  and  tincture  nux  vomica, 
if  given  as  a  stomachic,  in  5  to  10  drops. 

They  may  be  given  alone  or  in  combination,  with  smaller  individual 
doses. 

The  alkaloidal  form  of  administering  stomachics  is  often  of  value. 
Thus: 

Condurangin  (Abbott's),  '^^  grain  (o.ooi). 

Quassin  (Abbott's),  H7  to  H2  grain  (0.01-0.005). 

Condurangin  (Merck's),  Ko  to  H  grain  (0.0065-0.016). 

Quassin  (Merck's),  H2  to  3^  grain  (0.002-0.02). 

Hydrastin  (Merck's),  K  to  K  grain  (0.016-0.032). 

Strychnin  arsenici,  Hoo  grain  (0.00065),  ^^^  quassin,  Ko  grain  (0.0065), 
are  a  good  combination. 

Orexin,  y^  to  i  grain  (0.032-0.065),  can  be  given  in  bouillon  for  the 
same  purpose. 

In  the  gastritis  of  phthisis,  carbonate  of  creosote  or  guaiacol  carbonate, 
5  grains  (0.3)  each  t.i.d.  after  meals,  are  of  value. 

For  Nausea  and  Vomiting. — Cerium  oxalate,  i  grain  (0.065),  alone 
or  combined  with  soda  bicarbonate  or  bismuth  subnitrate,  2  grains 
(0.13),  or  any  of  the  methods  described  under  Acute  Gastritis.  Lavage 
may  be  necessary. 

For  Jaundice. — If  jaundice  is  present  with  chronic  gastritis  this  is 
an  evidence  that  duodenitis  is  associated.  The  treatment  would  be  the 
same  as  for  the  jaundice  from  complicating  duodenitis  with  acute  gastritis, 
and  is  described  under  that  heading. 

For  Belching. — Milk  of  magnesia,  3^  to  i  dram  (2.0-4.0),  or  magnesia 
usta,  10  grains  (0.6). 

For  Gastric  and  Intestinal  Fermentation. — Resorcin  resublimed, 
iH  drams  (6.0);  aqua  menthae  piperitae,  q.  s.  4  ounces  (125.0).  Dose, 
2  drams  (8.0)  t.i.d.  after  food  in  water,  or  ichthoform  or  ichthalbin, 
5  grains  (0.32)  each,  or  sodium  benzoate,  10  grains  (0.6)  t.i.d.,  etc. 


26o  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

The  following  prescriptions  are  also  excellent,  and  are  recommended 
by  William  H.  Thomson: 

I^.  Resorcinolis , 3iij  (12.0); 

Tr.  nucis  vomicae 3iv  (16.0); 

Syrup  zingiberis 5ij    (125.0); 

Aq.  menth.  piperit q.  s.  ad.  Oss   (250.0). — M. 

Sig. — Two  teaspoons  in  water,  half  an  hour  after  meals. 

I^.  Potassii  bichromatis gr.  iss  (0.096); 

Bismuthi  subcarb 3iss  (6.0); 

Ext.  gentianae q.  s.  ad. — M. 

Div.  in  pillulae,  xxx. 
Sig. — One-half  an  hour  before  meals. 

For  nervous  symptoms  associated  with  intestinal  putrefaction  I  would 
refer  to  the  chapter  on  the  latter  subject.  Iron  and  arsenic  can  also  be 
added  to  the  treatment,  such  as  a  Blaud's  gr.  v.  pill  containing  gr.  J^o 
sod.  arum. 

For  Constipation. — Patients  under  treatment  with  the  Carlsbad 
waters  require  no  treatment  for  constipation;  otherwise  attention  must 
be  paid  to  this  condition. 

The  patient  should  have  a  movement  every  day,  go  to  the  closet 
at  a  definite  hour,  and  endeavor  to  secure  bowel  action.     This  can  be' 
assisted  by  a  2-ounce  injection  of  olive  oil,  or  by  a  glycerin  or  gluten 
suppository,  or  2  drams  to  3-^  ounce  (8.0-16.0)  glycerin  in  i  ounce  (30.0) 
of  water,  by  means  of  a  small  rectal  syringe. 

Green  vegetables,  such  as  spinach,  asparagus,  lettuce,  green  peas, 
etc.,  are  of  service. 

Stewed  fruits,  such  as  prunes,  apples,  or  pears,  are  often  effectual. 

Some  cases  do  well  with  food  containing  much  cellulose  and  with  rye 
bread,  but  many  cannot  take  them.  A  glass  of  cold  or  hot  water  on  rising 
is  of  value. 

If  mild  cathartics  are  necessary,  cascara  (fluidextract),  y^  to  i  dram 
(2.0-4.0),  or  the  aromatic  fluidextract;  or  extract  cascara,  i  to  2  grains 
(0.065-0.13);  or  regulin,  i  to  2  drams  (4.0-8.0)  at  meals;  or  compound 
rhubarb  pills — all  at  night.  Russian  mineral  oil  5ss  a.  m.  and  p.  m.  is 
often  of  value;  or  one  of  the  American  mineral  oils  as  a  substitute. 

The  following  prescriptions  are  of  service: 

I>.  Aloin gr-  K  (o-oi6); 

Podophyllin gr.  3^  (o.oii); 

Atropin.  sulph.  1  w       /  ,  n 

Strychnin  / aa  gr.  Hoo  (0.00065); 

Cascara  ext gr.  }^  (0.016). — M. 

In  one  pill. 

I^.  Ext.  aloes  | 

Ext.  nucis  vomicae  \ aS  gr.  y^  (o .  008). — M. 

Ext.  belladonnae      J 
In  one  pill. 


I^.  Podophyllin gr.  ]^  (o .  oi  i) ; 

Ext.  nucis  vomicae 

Ext.  physostig. 
In  one  pill. 


\ S^gT.  14  (0.016).— M. 


CATARRH  OF  THE  STOMACH  261 

I^.  Aloin gr.  }i  (0.016); 

Strychnin gr.  J6  (0.00108); 

Ext.  belladonnae gr.  H  (0.008). — M. 

In  one  pill. 
Other  remedies  are  described  under  Constipation. 

Olive-oil  injections  5viii-oi  to  be  retained  at  night;  an  occasional 
enema  of  soapsuds,  not  over  i  quart  (liter);  massage  or  vibratory  mas- 
sage or  electricity  to  the  intestines  are  useful. 


CHAPTER  XI 

ACHYLIA   GASTRICA— ACHLORHYDRIA  HEMORRHAGICA 

GASTRICA 

ACHYLIA  GASTRICA 

{Synonyms. — Atrophy  of  the  Stomach;  Atrophy  of  the  Gastric  Mucosa;  Anadenia 
Ventriculi;  Phthisis  Ventriculi;  Atrophic  Gastritis;  Catarrhus  Atrophicans.) 

Definition. — Achylia  gastrica  (the  term  first  suggested  by  Einhorn) 
may  be  defined  as  a  functional  perversion  of  the  stomach,  characterized 
by  the  absence  of  the  gastric  secretion  (of  hydrochloric  acid,  pepsin,  and 
rennet). 

Introduction. — In  many  cases,  atrophy  of  the  mucosa  is  the  cause,  and 
the  condition  is  permanent.  Einhorn,  however,  has  reported  a  case  in 
which  there  was  eventually  some  return  of  secretion,  so  that  portions  of 
the  mucosa  could  have  not  been  much  altered;  and  a  case  of  achylia  in  a 
vegetarian,  apparently  an  atrophy  from  disuse.  Achylia  gastrica  may 
result  from  organic  changes  in  the  stomach,  or  may  be  a  pure  neurosis,  or 
a  temporary  disturbance  of  function,  so  I  prefer  to  place  it  in  a  special 
chapter. 

The  loss  of  function  may  be  temporary  from  nervous  disturbances,  and 
A.  Rose^  and  the  author^  have  observed  achylia  occurring  in  gastroptosis, 
with  a  return  of  secretion  following  the  cure  of  ptosis,  the  latter  ap- 
parently being  a  factor,  though  causing  disturbances  of  the  circulation. 
Temporary  achylia  is  present  occasionally  with  mucous  colic. 

History. — Atrophy  of  the  gastric  mucosa  was  first  described  in  connec- 
tion with  pernicious  anemia  by  S.  Fen  wick,  ^  and  later  by  Lewy^,  Ewald,^ 
Osler,^  Kinnicutt,'^  Nothnagel,  Boas,  and  others.  It  was  beUeved  to  be 
the  cause  of  pernicious  anemia  and  productive  of  the  fatal  result  Herter 
has  demonstrated  the  influence  of  intestinal  putrefaction,  chiefly  through 
the  gas  bacillus  (Bacillus  aerogenes  capsulatus),  in  the  production  of 
pernicious  anemia,  and  favorable  results  produced  by  intestinal  irrigation 
and  lactic  acid  fermented  milk  diet.  Stockton  has  called  to  our  attention 
that  achylia  does  not  occur  in  the  early  stages  of  pernicious  anemia,  but 
only  when  it  becomes  severe.  In  view  of  these  facts,  achylia  seems  to  be 
a  secondary  and  not  a  primary  cause. 

Numerous  non-fatal  cases  of  achylia  have  been  reported  by  Ewald,* 

^  Atonia  Gastrica,  Rose  and  Kemp. 

'Observations  on  Dilatation  of  the  Stomach  and  Gastroptosis,  Medical  News, 
August  6,  1904.     Mucous  Colic,  American  Medicine,  March  4,  1905. 
'Lancet,  July,  1877. 
*  Berlin,  klin.  Wochenschr.,  1887,  No.  4. 
'Ibid.,  1886,  No.  32. 

•Amer.  Jour,  Med.  Sci.,  vol.  xci,  1886,  p.  498. 
'Ibid.,  1887,  p.  419. 

'Berliner  klin.  Wochenschr.,  1892,  Nos.  20  and  27. 

262 


ACHYLIA   GASTRICA  263 

Boas,  Einhorn,^  Jaworski,  Jones,  and  Martins,  and  the  latter  has  written  a 
work  on  the  subject. 

Etiology. — Severe  chronic  catarrhal  gastritis,  or  toxic  gastritis,  may 
produce  permanent  destruction  of  the  glands;  atrophy  from  disuse,  as  in 
vegetarians;  achylia,  associated  with  cirrhosis  of  the  liver  (syphilis);  or 
with  carcinoma  of  the  stomach,  or,  rarely,  with  carcinoma  of  other  organs, 
occasionally  with  diabetes  mellitus;  achylia  with  pernicious  anemia  and 
rarely  with  gastric  ulcer  and  achlorhydria  hemorrhagica  gastrica.  Organic 
changes  are  present  in  most  of  these  cases.  Achylia  may  occur  as  a 
temporary  functional  disturbance  in  nervous  conditions,  neurasthenia, 
gastroptosis,  achlorhydria,  hemorrhagica,  gastrica,  and  mucous  colic. 
Achylia  may  also  be  secondary  to  a  general  infection,  such  as  typhoid 
fever,  grippe,  pellagra,^^  etc. 

Age. — It  is  quite  common  in  the  middle  and  later  years  of  life,  but  has 
occurred  in  a  number  of  young  persons,  especially  in  the  transitory  type. 

Morbid  Anatomy. — When  the  achylia  is  of  nervous  origin,  or  associated 
with  gastroptosis  or  mucous  colic,  there  are  no  organic  changes  in  the 
mucosa,  and  the  condition  is  a  temporary  functional  disturbance  of  secre- 
tion. Rose  and  myself  believe  the  achylia  in  mucous  colic  due  to  the 
gastroptosis  and  not  to  the  nervous  condition. 

Einhorn  has  shown  that  in  cases  where  a  portion  of  the  mucous  mem- 
brane has  been  aspirated,  showing  the  organic  changes  of  achylia,  there  has 
been  some  return  of  secretory  function  under  treatment,  so  that  this  is  no 
evidence  of  permanent  destruction  of  secretory  power  in  all  the  gastric 
glands. 

Of  the  organic  changes,  there  are  the  two  t)^es  described  under  the 
terminal  stage  of  chronic  gastritis: 

1.  Phthisis  venticuli — round-celled  infiltration  and  fatty  degeneration, 
with  thinning  of  the  stomach  wall;  round  cells  taking  the  place  of  the 
glands;  and  the  stomach  is  normal  in  size  or  may  be  dilated  (Fig.  181). 

2.  Cirrhosis,  or  sclerosis  ventriculi,  a  fibrous  inflammation,  starting  in 
the  submucosa,  fibrous  tissue  takes  the  place  of  the  glands,  and  the  stomach 
is  contracted  and  the  walls  thickened. 

Sjrmptoms. — One  can  scarcely  say  that  there  are  symptoms  character- 
istic of  achylia  gastrica;  it  is  the  examination  of  the  gastric  contents  which 
will  alone  determine  the  true  diagnosis.  In  describing  the  symptoms,  it 
seems  best  to  classify  achylia  under  certain  groups,  some  of  which  we 
may  dismiss  briefly: 

1.  Gastroptosis  (splanchnoptosis),  with  its  symptoms;  gastric  disturb- 
ances; achylia  is  present  in  some  cases. 

2.  Mucous  colic,  with  its  symptoms;  occasional  presence  of  achylia. 

3.  Patients  with  no  symptoms  and  enjoying  good  health.  Einhorn  calls 
attention  to  this  class,  one  of  which  had  the  habit  of  rumination,  and  achy- 
lia was  found  present,  of  forty  years'  duration.  Patient  had  no  other 
symptom.     Clinically  this  class  cannot  be  considered. 

4.  Cases  with  gastric  symptoms  of  varying  severity,  associated  with 
intestinal  disturbances.     These  are  the  most  common  type. 

»  New  York  Med.  Presse,  Sept.,  i886. 

*  Stockton,  Amer.  Jour.  Med.  Sci.,  Aug.,  1909. 


264 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


There  are  loss  of  appetite,  a  feeling  of  fulness  or  pressure  in  the  epigas- 
tric or  gastric  regions,  and  in  some  cases  severe  paroxysms  of  pain,  usually- 
soon  after  eating  and  persisting  for  some  time;  vomiting  may  occur  soon 
after  the  ingestion  of  food;  belching  of  gas;  headache  and  occasionally 
vertigo;  usually  constipation,  sometimes  diarrhea. 

Some  cases  may  remain  fairly  well  nourished.  In  others  there  may  be 
considerable  loss  of  weight,  which  extends  over  a  period  of  several  years, 
and  nervous  symptoms  may  be  present. 

In  cases  in  which  nutrition  is  preserved,  the  intestines  perform  the 
digestive  functions  of  the  gastro-intestinal  tract. 


jif^T^^.. 


Fig.  181.— Achylia  gastrica:  i,  Mucosa;  2,  submucosa;  3  and  4,  muscularis;  5, serosa; 
section  shows  round-celled  infiltration  of  mucosa  and  absence  of  glands. 

Einhorn  describes  cases  whose  symptoms  resemble  hyperchlorhydria, 
with  pains  one  to  two  hours  aft^r  eating,  which  are  relieved  by  food  and 
drink,  especially  the  latter,  which  prevents  irritation  of  the  mucosa  by  the 
coarse  particles.     This  has  been  given  as  an  explanation  for  the  pain. 

5.  Cases  with  marked  intestinal  disturbances,  especially  diarrhea,  or 
occasionally  diarrhea  alternating  with  constipation;  quite  frequently  there 
raiay  be  no  gastric  symptoms  or  slight  belching  or  a  feeling  of  pressure. 

Some  of  the  cases  lose  considerable  weight  and  strength  and  feel  weak. 
I  have  recently  treated  a  case  suffering  from  these  symptoms  who  was,  in 
addition,  markedly  nervous.     At  the  end  of  four  months'   treatment 


ACHYLIA    GASTRICA  26$ 

gastric  secretion  returned  and  all  symptoms  disappeared,  there  being  15 
pounds  increase  in  weight — a  case  of  nervous  achylia. 

Some  cases  of  this  type  may  present  symptoms  (subjective)  of  diabetes, 
according  to  Einhorn. 

6.  Cases  with  severe  anemia  (described  by  Riegel)  with  diarrhea. 
Examination  of  the  blood  shows  secondary  anemia,  and  of  the  stomach, 
achylia  gastrica.  Diarrhea  favors  the  production  of  anemia  and  the  latter 
improves  under  treatment.  These  cases  must  not  be  confounded  with 
pernicious  anemia.     The  blood  examination  easily  differentiates. 

7.  Achylia  developing  during  acute  febrile  conditions,  such  as  influenza 
(Ewald)  typhoid,  etc.  Riegel  believes  it  probably  preexisted,  and  that  the 
intestines,  which  formerly  performed  the  digestive  functions,  are  thus 
disturbed  and  achylia  symptoms  first  appear  in  consequence. 

8.  Patients  suffering  from  nervous  conditions,  or  neurasthenia,  or 
gastric  neuroses;  achylia  a  temporary  perversion. 

My  case  under  the  diarrheal  class  belonged  to  this  type. 

9.  Pernicious  anemia  with  achylia,  in  which  the  blood-findings  are 
typic;  megalocytes  and  nucleated  red  blood-corpuscles  (normoblasts  and 
megaloblasts),  etc. 

Diagnosis. — The  diagnostic  feature  of  achylia  is  the  gastric  analysis 
one  hour  after  Ewald's  test-breakfast.     The  characteristics  are  as  follows: 

Total  acidity  is  2+  to  4-f-  ,  or  even  neutral;  HCl  =  O;  pepsin  =  O; 
rennet  =  O  (rennet  zymogen  may  be  present);  propetone  =  O;  peptone 
=  O;  lactic  acid  =  O;  or  faint  trace;  erythroodextrin  =  O;  sugar  =  -f ; 
gastric  contents  have  no  odor,  no  evidence  of  fermentation;  quantity  of 
liquid  is  very  small,  aside  from  that  soaked  into  the  particles  of  bread 
(this  is  quite  characteristic) ;  bread  particles  are  not  minutely  minced,  but 
rather  coarse;  absence  of  mucus. 

Schmidt  and  Riegel  believe  mucus  to  be  present  in  some  cases  in  the 
early  stage  of  achylia,  developed  from  chronic  gastritis,  while  there  are 
some  glands  remaining  in  mucoid  degeneration,  and  that  the  presence 
of  mucus  does  not  signify  that  the  case  is  not  one  of  achylia.  Some  cases 
of  old  chronic  gastritis  certainly  seem  on    the   borderline. 

The  small  amount  of  fluid  in  achylia  is  explained  by  the  fact  that  the 
liquid  chyme  rapidly  leaves  the  stomach,  leaving  the  solid  particles,  and 
that  practically  no  secretion  takes  place  in  the  stomach. 

Motor  function  is  often  normal  or  even  increased.  It  is  diminished 
where  there  is  degeneration  with  dilatation  of  the  stomach. 

Absorption. — Though  this  has  apparently  seemed  normal  by  the 
iodid  of  potash  test,  in  some  cases  it  is  evident  that  this  test  is  often 
fallacious,  in  view  of  the  fact  of  the  general  loss  of  nutrition  in  some 
patients. 

I  agree  with  Riegel  that  from  the  pathologic  condition  present,  absorp- 
tion must  be  diminished. 

Course  and  Prognosis. — In  nervous  achylia,  secretion  may  be  resumed 
in  a  few  months  under  proper  treatment,  and  in  gastroptosis  and  mucous 
colic  the  condition  is  dependent  on  the  treatment  of  these  diseases. 

In  some  patients  the  condition  perhaps  exists  for  years,  with  the 
patient  in  good  health;  while  in  others  the  subjective  symptoms  may  be 


266 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


removed  or  cured,  while  the  objective  symptom  (the  analysis)  persists. 
Others  run  a  long  and  protracted  course. 

With  pernicious  anemia  and  carcinoma  the  prognosis  of  achylia  depends 
on  the  primary  disease. 

Diagnosis. — Repeated  analyses  of  the  gastric  contents  are  necessary  to 
arrive  at  the  diagnosis. 


Achylia  Gasirica. 

Gastric  contents: 
Little  fluid,  no  mucus,  low  acid  reac- 
tion (2+  to  4+),  no  HCl,  no  pepsin, 
no    rennet,    no    lactic    add,    coarse 
particles,  no  blood. 

Stool: 

No  blood. 
Tongue: 

Often  clean. 
Pain: 

At  times. 
Motor  power: 

Normal  usually. 
Course: 
Slow. 
Loss  of  weight: 

Gradual. 
Cachexia: 

None,  or  slow  emaciation. 
Tumor: 
None. 
Achlorhydria  Haemorrhagica  Gastrica. — 
There  are  numerous  bacteria  and  occult 
blood  in  the  gastric  contents,  yellow  tinge, 
total  acidity  6+  to  8+  biuret  reaction+ 
rennet4-;  mucus-H    secondary    to   other 
diseases  or  surgical  conditions. 

Some  advocate  the  Wolff- Junghans  test  as  a  means  of  differentiating 
carcinoma  from  achylia  gastrica. 

The  possibility  of  achylia  gastrica  being  the  cause  of  various  types  of 
gastro-intestinal  disturbances,  of  chiefly  intestinal  derangement  or  irregu- 
larities, or  of  severe  anemia  must  be  considered.  Its  association  with 
pernicious  anemia,  gastric  neuroses,  various  nervous  symptoms,  gas- 
troptosis,  and  mucous  colic  must  be  remembered.  These  facts  further 
emphasize  the  importance  of  gastric  analysis. 

Treatment. — This  depends  on  the  cause.  Rose's  belt,  if  achylia  is 
due  to  gastroptosis  or  mucous  colic,  is  necessary.  If  associated  with 
nervous  affections,  these  conditions  should  receive  treatment.  Such 
patients  should  have  their  nutrition  improved,  and  be  placed  on  the  diet 
shortly  to  be  laid  down.  As  in  these  cases  achylia  is  a  functional  disturb- 
ance, the  secretion  should  be  stimulated  by — 

Strychnin,  Ho  to  Ho  grain  (0.00108. 0.0021),  t.i.d.  before  meals,  or 
condurango  (fluidextract),  15  to  20  minims  (0.88-1. 18),  or  tincture  nux 
vomica,  5  to  10  minims  (0.29-0.59),  with  the  addition  of  hydrochloric 
acid,  thus: 


Cancer  of  the  Stomach. 

Gastric  contents: 
Mucus,  acidity  higher,  lactic  acid,  free 
HCl  may  be  present,  though  usually 
absent,  contents  more  fluid,  and  odor 
and  food  less  coarse,  blood  or  occult 
blood  present.     Boas-Oopler  bacilli. 

Blood,  or  occult  blood. 

Coated. 

Constant. 

Diminished. 

Rapid. 

Rapid. 

Rapid  and  peculiar  type. 

Present  later. 

Chronic  Gastritis. — There  is  much 
mucus  in  the  gastric  contents  and  pepsin 
and  rennet  are  present;  HCl  is  diminished 
or  absent.    Higher  acidity. 


ACHYLIA   GASTBICA  267 

I^.  Tinct.  nucis  vomica       "I  ^   ^...  ,        v 

Acid,  hydrochlor.  dilut.  / ^  ^"^  U2.0;; 

Comp.  tinct.  cinchona 5  J  (30  •  o)  J 

Pure  pepsin 3iss  (6.0); 

Aq.  destil q.  s.  ad.  giv  (125.0). — M. 

Sig. — Two  drams  in  water  t.i.d.  before  meals  (preferably). 

Pancreatin,  5  to  10  grains  (0.3-0.6),  with  soda  bicarbonate,  15  grains 
(i.o),  holadin  or  pancreon,  5  grains  (0.5),  given  three  times  a  day,  are  useful 
to  aid  intestinal  digestion,  or  taka-diastase,  5  grains  (0.33),  can  be  given 
after  meals  in  cases  with  diarrhea  to  aid  digestion  of  starch  food.  Cellasin 
tablets,  5  grains  (0.3),  t.i.d.,  are  also  useful. 

In  the  general  treatment  of  achylia  gastrica  endeavor:  (i)  To 
stimulate  gastric  secretion.  (2)  To  aid  intestinal  digestion  as  noted  above. 
(3)  To  arrange  the  diet  so  that  the  food  is  easily  digested. 

To  stimulate  gastric  secretion  employ  stomachics,  such  as  nux  vomica, 
condurango,  etc.,  fifteen  minutes  before  meals,  as  just  described.  The 
occasional  use  of  lavage  twice  a  week  is  of  service  in  some  cases.  Litten 
advises  the  use  of  a  2  per  cent,  dilute  hydrochloric  acid  solution  for  this 
purpose. 

Van  Noorden  has  employed  hepptin  (the  natural  gastric  juice  of  the 
pig)  with  success  in  some  cases,  in  tablespoon  doses,  three  times  a  day. 
It  can  be  given  after  meals  in  water,  seltzer,  or  tea.  If  administered  in 
milk,  it  will  coagulate  the  same  if  it  is  warm,  but  it  can  be  taken  by  this 
method.  Oxyntin  (a  hydrochloric  acid  preparation  in  powder  form)  can  be 
given  in  capsules,  5  grains  (0.3),  each  alone  or  with  nux  vomica.  Dose, 
one  to  two  capsules  three  times  daily  before  meals.  They  can  be  secured 
already  prepared. 

Intragastric  faradization  (preferably)  twice  a  week  or  percutaneous 
faradization  may  be  valuable,  I  would  not  advise  this  in  the  purely  nervous 
cases. 

If  the  symptoms  simulate  hyperchlorhydria,  the  use  of  water,  8  ounces 
(250  c.c),  or  crackers  and  milk  one  to  two  hours  after  meals,  as  suggested 
by  Einhorn,  lessens  the  irritation. 

Diet. — This  is  very  important.  Food  should  be  prepared  so  as  to  pass 
readily  from  the  stomach,  and  should  be  finely  divided  and  thoroughly 
masticated.  Meat  should  be  given  in  small  quantity,  finely  chopped, 
scraped  (rare  or  broiled),  chicken,  pigeon,  raw  scraped  beef,  calves'  brain, 
steak,  fish,  and  game. 

Starchy  foods  are  excellent  and  should  be  thoroughly  prepared;  mem- 
branes covering  any  such  should  be  removed.  Starch  is  rapidly  converted 
into  sugar. 

Mushes  and  liquids  are  preferable.  Pea  and  bean  soup  (strained), 
purees,  barley,  oatmeal,  rice,  sago,  and  potato  soups.  Mushes  from  rice, 
potato,  tapioca,  oats,  flour,  etc;  puddings.  Soft-boiled  eggs;  yolks  of  eggs 
in  soups;  raw  eggs  beaten  with  water  or  milk;  koumiss;  matzoon;  ba- 
cillac;  bread;  crackers;  milk,  plenty  of  cream  up  to  half  a  pint,  and  butter 
up  to  yi-Yi  pound  daily  are  indicated.  Some  of  course  cannot  digest 
this  amount. 

Somatose,  tropon,  and  meat  powder;  Valentine's  or  Liebig's  beef-juice; 
Armour's  extract  of  beef  can  be  added. 


268  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Cocoa  possesses  considerable  nutritive  power.  Tea  and  coffee  well 
diluted  with  milk  can  be  given.  My  personal  view  is  that  alcoholic  bever- 
ages are  objectionable,  though  some  allow  them  in  moderation. 

The  second  indication  in  the  feeding  is  to  employ  it  at  frequent  inter- 
vals, about  every  three  hours,  in  small  quantities,  but  so  that  the  sum  total 
shall  be  considerable.  The  object  should  be  rather  to  overfeed  and  to 
increase  the  patient's  weight  by  selecting  those  foods  which  best  agree  in 
each  case. 

In  diarrheal  cases,  constipating  food,  such  as  potatoes  and  rice,  should 
be  selected.  Feed  by  the  "scales"  to  increase  body  weight  is  my  rule  in 
cases  where  loss  of  weight  has  occurred. 

For  the  preparation  of  meat  powder,  either  of  the  following  methods  is 
excellent : 

(i)  Debove's  Method. — Roast  finely  chopped  lean  beef  on  a  tin-plate 
until  desiccated,  then  powder  in  a  mortar. 

(2)  Einhorn's  Method. — Dry  j&nely  chopped  meat  three  to  six  hours  on 
a  stove;  then  pound  in  a  mortar  and  grind  twice  in  a  coffee-mill. 

Butter,  milk,  cream,  eggs  (soft  boiled  or  raw),  potatoes,  rice,  peas,  and 
beans  (strained  through  a  colander) ,  cocoa,  chocolate,  and  a  small  amount 
of  beef,  chicken,  or  game,  and  crackers  or  stale  bread  always  seem  to  agree. 
I  have  often  given  four  to  eight  eggs  a  day,  several  soft-boiled  and  the 
rest  raw  in  milk.     For  example: 

Calories 

8  A.  M.  Oatmeal  with  cream,  150  gm 400 

Cocoa  with  milk,  200  gm 135 

Soft-boiled  eggs  (2) 160 

Toast  ( 2  slices) 160 

Butter,  20  gm 163 

II  A.  M.  6  ounces  (200  c.c.)  milk  with  raw  egg 240 

Crackers,  2  oz.  (60  gm.) 150 

Butter,  20  gm 163 

2  p.  M.  Soup,  bean  or  pea,  100  gm.  (with  i  egg  and  10  gm.  of 

cane-sugar) 122 

Rare  meat  scraped,  100  gm 215 

Mashed  potatoes,  50  gm 63 

Spinach,  50  gm 30 

Bread,  2  slices  (60  gm.) 135 

Butter,  20  gm 163 

Tea  and  milk  (2  lumps  of  sugar) 60 

5.30  to  6  p.  M.  Soft-boiled  egg  (i) 80 

Rice,  50  gm.;  milk,  200  gm 302 

Bread  (i  slice) 67 

Butter,  20  gm 81 

Tea  and  milk 60 

9  to  9.30  p.  M.  6  ounces  (200  c.c.)  milk  oi-  koumiss 128 

Zwieback,  50  gm 1 29 

Butter,  20  gm 163 

Total  calories •. 3269 

It  may  be  necessary  to  modify  this  diet  and  give  less,  especially  at  first. 

In  cases  of  severe  anemia,  rest  in  bed;  arsenic  in  large  doses,  begin- 
ning with  Fowler's  solution,  5  minims  (0.296),  t.i.d.  and  increasing  to 
10  to  15  minims  (0.59-0.88)  t.i.d.;  or  by  hypodermic  in  sterile  water 
in  the  form  of  atoxyl,  H  to  %  grain  (0.022-0.044),  every  other  day  or 


ACHLORHYDRIA   HEMORRHAGICA    GASTRICA  269 

cacodylate  of  soda  and,  in  addition,  iron  tropon,  or  any  other  good  iron 
preparation. 

Intestinal  irrigation  is  of  value  in  these  cases  when  putrefactive  processes 
are  present  in  the  intestines,  for  example,  with  i  to  2  ounces  (30.0-60.0) 
peroxid  of  hydrogen  or  acetozone  15  grains  (i.o)  to  the  quart  (liter)  of 
water.  Enteroclysis  is  especially  advocated  in  pernicious  anemia  cases. 
Matzoon,  koumiss,  buttermilk,  bacillac,  lactone  buttermilk  are  suitable 
as  a  diet,  and  lactic  acid  bacilli  tablets  or  preferably  liquid  lactic  acid 
bacilli  in  tubes  internally  for  the  intestinal  putrefaction  present  in  this 
disease. 

I  have  found  hexamethylenamin  5  to  10  grains  (0.3-0.6),  alone  or 
preferably  combined  with  equal  quantities  of  benzoate  of  soda,  is  of  great 
service  as  a  remedy  for  intestinal  putrefaction. 

Resorcin  and  the  other  remedies  suggested  for  this  purpose  under 
Chronic  Gastritis  and  in  the  paragraph  on  Indicanuria  are  of  value. 

The  bismuth  preparations,  notably  bismuth  subcarbonate  or  sub- 
nitrate,  10  to  30  grains  (0.6-2.0)  t.i.d.,  can  be  given  if  diarrhea  is  present, 
and  in  this  type  boiled  milk,  potatoes  (mashed),  and  rice  are  serviceable. 

If  there  is  atonic  dilatation  of  the  stomach,  lavage  and  the  treatment 
for  this  condition  must  be  carried  out  and  Rose's  belt  applied. 

ACHLORHYDRIA  HEMORRHAGICA  GASTRICA 

Definition. — Achlorhydria  haemorrhagica  gastrica  is  characterized  by 
the  absence  of  hydrochloric  acid  in  the  gastric  secretion,  usually  the  result 
of  reflex  disturbance  from  disease  of  some  other  organ,  or  from  some  other 
primary  disease,  and  by  the  presence  of  gastric  erosions,  with  occult 
blood,  mucus,  and  a  large  number  of  organisms,  most  frequently  strep- 
tococci, colon  bacilli,  or  diplococci,  in  the  gastric  contents. 

Introduction. — This  condition  has  been  extensively  investigated  by 
the  Mayos  of  Rochester  in  a  large  series  of  cases.  In  seven  instances 
a  reflex  achylia  gastrica  (absence  of  all  the  secretions)  was  present.  The 
disease  is  somewhat  difflcult  to  classify,  though  it  appears  usually  to  be  the 
result  of  a  reflex  disturbance  of  gastric  secretion,  with  a  secondary  in- 
fection of  the  mucosa.  From  the  presence  of  mucus  in  the  gastric  con- 
tents it  might  be  allied  to  a  chronic  gastritis  of  an  infected  type  following 
a  reflex  disturbance  of  gastric  secretion. 

J.  T.  Pilcher'  reports  271  cases  from  a  large  mass  of  material,  or  ap- 
proximately one  in  every  fifteen  stomachs  examined  after  the  Ewald 
test-meal.  As  a  further  demonstration  that  achlorhydria  haemorrhagica 
gastrica  is  a  reflex  disturbance,  it  proved  interesting  to  note  the  disap- 
pearance of  all  gastric  symptoms  after  removal  of  the  primary  irritant, 
such  as  the  appendix,  gall-stones,  etc. 

Etiology. — In  156  out  of  271  cases  of  achlorhydria  haemorrhagica 
gastrica  reported,  the  onset  of  the  gastric  symptoms  seemed  to  bear  an 
immediate  relation  to  other  diseases;  to  infectious  diseases  in  38  cases; 
to  circulatory  disturbances  in  12;  to  postoperative  development  in  14; 

^  Pathological  Laboratories  of  St.  Mary's  Hospital,  Rochester,  Minn.,  and  Jour. 
Amer.  Med.  Assoc.,  Nov.  iq,  1910. 


270  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

and  to  derangement  of  the  ductless  glands  in  24  cases.  In  100  cases  an 
operation  was  performed  while  achlorhydria  haemorrhagica  gastrica  was 
present.  The  appendix  was  involved  in  36  cases;  the  gall-bladder,  in 
32;  the  gall-bladder  and  pancreas,  in  16,  and  in  the  stomach  there  were 
16  cases  in  which  there  was  some  additional  lesion.  There  were  12  cases 
in  which  the  appendix  and  gall-bladder  were  together  diseased.  Reflex 
nervous  phenomena  are  doubtless  primarily  responsible  for  the  inhibition 
of  the  production  of  hydrochloric  acid  in  these  cases,  for  it  is  a  well-known 
fact  that  irritation  in  distant  organs  may  produce  an  extraordinary  degree 
of  gastric  disturbance. 

Morbid  Anatomy.— In  64  cases  the  stomach  and  pylorus  were  ap- 
parently normal.     In  24,  pylorospasm  was  demonstrated  on  the  operating 


Fig.  182. — Gross  appearance  of  posterior  wall  of  stomach,  showing  non-contiguous 
erosions  or  superficial  ulcerations  in  fundus  (J.  T.  Pilcher). 

table.  It  accompanied  appendicitis  in  18  cases  and  gall-bladder  involve- 
ment in  6.  In  4  cases  previous  gastro-enterostomies  were  cut  ofif,  as  they 
seemed  not  to  be  required.  In  several  cases  other  lesions  of  the  stomach 
were  also  present.  In  2  cases,  ulcer;  in  i,  pyloric  insufficiency;  in  3  the 
pylorus  was  much  thickened;  there  was  i  congenital  stenosis  of  the 
pylorus  and  i  hour-glass  contraction. 

Microscopic  Examination. — In  3  cases  specimens  of  the  gastric  mucosa 
were  secured  for  examination.  There  were  non-contiguous  erosions  or 
ulcerations  extending  down  to  the  muscular  coat  and  a  submucous  infil- 
tration of  round  cells  (Fig.  182).  In  many  places  there  was  a  marked 
engorgement  of  the  capillaries  due  to  the  inflammatory  reaction.  There 
were  masses  of  yellowish  blood  pigment  lying  irregularly  over  the  epithe- 
lium which  are  not  found  in  the  normal  organ.     It  was  believed  that  they 


ACHLORHYDRIA   HEMORRHAGICA   GASTRICA  271 

were  probably  due  to  precipitation  of  the  ferruginous  element  contained 
in  the  blood-serum  which  had  exuded  from  the  eroded  and  inflamed  areas. 

Bacteriology. — These  cases  are  characterized  by  the  presence  of  a 
large  number  of  pathogenic  organisms  in  the  stomach,  particularly  strepto- 
cocci and  colon  bacilli.  Their  presence  in  great  numbers  is  believed  to 
be  due  to  the  lowered  acidity  of  the  gastric  juice  (absence  of  hydrochloric 
acid).  The  examination  of  350  specimens  from  150  stomachs  showed 
the  following  results:  Streptococci  in  127  cases,  colon  bacilli  alone  in 
8,  streptococci  and  colon  bacilli  in  64,  diplococci  (marked)  in  84,  lactic 
acid  bacilli  in  42. 

Staphylococci,  the  proteus,  and  leptothrix  were  always  present.  In 
several  cases  the  cells  of  the  mucosa  possessed  phagocytic  properties. 
Degenerated  leukocytes  were  almost  always  present,  sufficient  to  be 
designated  as  pus  in  48  cases.  The  bacteria  were  actively  growing. 
Streptococci  are  apparently  the  most  important  factors,  since  they  Oc- 
curred in  larger  numbers  in  those  cases  in  which  pus  was  present.     Prob- 


r 

-■Bfttf^lmf. 

1 

^ 

^^9*    'mmEy'  tfr*i 

^ 

¥ 

m^^ 

^m: 

*i 

■  ,^^^^im 

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__^^ 

^ 

mm 

Fig.  183. — Photomicrograph   through   defect    in   mucosa    in   Fig.    182,   showing  de- 
struction of  epithelium  and  round-cell  infiltration  of  submucosa  (J.  T.  Pilcher). 

ably  the  active  irritation  accounts  for  the  presence  of  the  erosions,  and 
the  latter  are  responsible  for  the  pain.  The  yellow  color  in  the  gastric  con- 
tents and  the  occult  blood  reaction  must  be  due  to  the  oozing  of  serum 
and  blood  from  the  erosions. 

Gastric  Analysis. — The  results  of  analysis  of  the  gastric  contents  are 
quite  characteristic.  The  Ewald  test-breakfast  with  water  (not  tea) 
is  administered,  and  an  hour  later  the  contents  are  withdrawn.  The 
amount  recovered  is  usually  less  than  that  ingested.  The  bread  is  in  a 
coarse  state  of  division,  practically  as  it  has  been  swallowed.  There  is 
no  viscosity,  but  the  bread  is  frequently  incorporated  in  thin  mucus.  The 
color  of  the  contents  is  quite  characteristic — varying  from  a  yellow  tinge, 
just  off  the  white,  to  a  light  orange.  Occasionally  there  is  a  slight  rancid 
odor.     The  filtrate  is  clear  and  may  have  a  yellow  tinge.     Remnants 


272  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

of  former  meals  are  seldom  found,  and  if  present  are  due  to  a  continuous 
pylorospasm.  The  biuret  reaction  is  usually  present  and  also  milk  coagu- 
lation, showing  there  is  no  true  "achylia."  In  seven  cases,  however, 
"achylia"  was  present. 

Free  hydrochloric  acid  is  absent  and  combined  acids  are  practically 
negative,  though  traces  have  been  found. 

Lactic  acid  is  present  in  about  15  per  cent,  of  cases.  The  Strauss 
method  of  determining  lactic  acid  the  investigators  deem  preferable,  as 
by  that  of  Ufifelmann  the  reaction  is  usually  obtained. 

Blood. — The  reaction  for  occult  blood  is  always  present.  Pilcher 
employs  the  modified  guaiac  test,  but  the  benzidin  test  is  satisfactory 
also. 

Symptoms. — The  symptoms  are  somewhat  inconstant  and  capricious, 
but  these  features  are  suggestive  of  the  diagnosis  when  considered  with 
the  other  facts.  In  the  majority  of  cases  there  is  oppression  or  distress 
in  the  epigastrium,  amounting  usually  to  a  sensation  of  pain.  This  is 
generally  of  a  burning,  gnawing  character,  and  occurs  in  about  one-third 
of  the  cases  immediately  after  the  ingestion  of  food,  and  acids  increase 
the  pain.  Sometimes  the  pain  comes  on  much  later  or  even  before  meals. 
It  is  usually  increased  by  taking  food,  though  it  may  be  temporarily  re- 
lieved thereby.  Vomiting,  particularly,  relieves  the  pain,  as  do  also 
alkalis  and  lavage.  There  is  considerable  belching,  and  sour,  bitter, 
acrid,  eructations  occur,  probably  due  to  the  formation  of  organic  acids. 
In  about  half  the  cases  vomiting  of  the  ingesta  occurs  immediately  after 
meals,  and  the  vomitus  has  a  sour,  bitter  taste.  Nausea  is  quite  frequent, 
and  hematemesis  has  occurred  in  a  few  cases.  Constipation  is  the  rule, 
but  it  may  alternate  with  periods  of  diarrhea  of  from  one  to  four  weeks' 
duration.  In  some  cases  the  bowel  movements  may  occur  directly  after 
eating.  The  appetite  is  usually  impaired,  though  vagaries  are  noted,  and 
these  patients  discriminate  as  to  the  quantity  and  quality  of  their  food, 
usually  first  discarding  meats  and  fats.  There  is  generally  a  loss  of  weight 
of  from  15  to  25  pounds.  These  patients  generally  present  a  perverted 
mental  attitude,  having  periods  of  depression  alternating  with  nervous 
excitement.  This  mental  condition  is  probably  due  more  to  worry  over 
their  disturbed  digestion  or  to  the  fear  of  cancer  than  to  a  neurosis.  The 
patient  suffers  from  malaise,  is  easily  fatigued,* is  unable  to  work,  has 
occasional  headaches,  and  at  times  insomnia. 

Diagnosis. — The  diagnosis  of  achlorhydria  haemorrhagica  gastrica  is 
usually  not  particularly  difficult,  as  it  generally  results  as  a  reflex  from 
primary  disease  in  some  other  organ.  The  determination  of  gall-bladder 
disease,  appendicitis,  pancreatic  disease,  or  some  other  primary  disease 
is  at  once  suggestive,  as  are  the  restoration  of  hydrochloric  acid  and 
the  disappearance  of  occult  blood  after  operation  for  a  surgical  condition 
extraneous  to  the  stomach,  or  after  the  cure  of  some  other  medical  con- 
dition. The  absence  of  hydrochloric  acid,  presence  of  occult  blood  mucus, 
and  the  large  number  of  organisms,  streptococci,  colon  bacilli,  etc.,  in 
the  gastric  contents,  and  the  other  peculiarities  of  these  contents  as  already 
described  as  pathognomonic. 

Gastric  Ulcer. — Free  hydrochloric  acid,  in  the  acute  cases  in  excess,  is 


ACHLORHYDRIA   HEMORRHAGICA    GASTRICA  273 

usually  present.  Examination  of  the  gastric  contents  shows  no  mtictis 
and  the  large  number  of  various  types  of  bacteria.  Bacteria,  however, 
are  present.  The  gastric  contents  do  not  present  the  peculiar  appearance 
of  achlorhydria,  and  in  the  latter  the  total  acidity  is  very  low,  6+  to  8+, 
and  free  HCl  is  absent.  At  times,  however,  one  meets  with  cases  of  gastric 
ulcer  with  an  absence  of  hydrochloric  acid,  and  the  possibility  that  an 
erosion  of  achlorhydria  hsemorrhagica  gastrica  may  become  an  ulcer  must 
be  considered.  Under  Gastric  Ulcer,  the  writer  refers  to  the  view  that 
gastric  ulcer  does  not  result  from  an  erosion.  In  the  case  of  achlorhydria 
haemorrhagica,  however,  there  are  erosions  plus  an  infection  with  various 
organisms,  notably  colon  bacilli.  The  experiments  of  Tiirck  show  that 
by  feeding  dogs  with  pure  cultures  of  colon  bacilli  one  may  produce  gastric 
ulcer.  Hence,  it  is  possible  that  an  erosion  of  achlorhydria  haemorrhagica 
gastrica  may  develop  into  an  ulcer.  In  fact,  Mayo  refers  to  two  cases  of 
gastric  ulcer  associated  with  this  condition.  The  type  of  gastric  ulcer 
with  absence  of  hydrochloric  acid  would  in  some  cases  seem  to  be  the 
probable  result,  such  as  Connors'  case,  under  Gastric  Ulcer. 

Carcinoma  of  the  Stomach. — ^The  age  of  the  patient,  rapidly  progres- 
sive emaciation,  and  anemia  associated  with  the  gastric  symptoms  are 
suggestive.  There  is  more  usually  absence  of  free  hydrochloric  acid  (though 
in  some  cases  in  the  early  stage  it  may  be  present  to  even  considerable 
amount).  Lactic  acid  and  Boas-Oppler  bacilli  are  present.  They  may 
be  absent  in  the  early  stage  if  HCl  is  present.  The  gastric  contents  do 
not  present  the  peculiar  appearance  of  achlorhydria  haemorrhagica  gastrica,. 
though  blood  or  occult  blood  is  present.  The  total  acidity  in  cancer  is 
usually  higher.  There  are  not  the  numerous  varieties  of  bacteria  in  excess. 
There  is  usually  disturbance  of  the  motor  functions  of  the  stomach  in 
cancer.  With  achlorhydria  haemorrhagica  there  is  some  primary  cause. 
Carcinoma  may,  however,  develop  from  achlorhydria  haemorrhagica 
gastrica  from  an  erosion.     X-rays  show  gastric  deformity  with  cancer. 

Chronic  Erosions. — There  are  the  characteristic  pieces  of  mucosa 
found  in  the  wash-water.  Usually  chronic  gastritis  is  present,  though 
occasionally  hyperchlorhydria.  The  peculiar  yellow  appearance  of  the 
gastric  contents  is  absent,  and  there  are  no  excessive  numbers  of  various 
bacteria.     The  condition  is  not  a  reflex  from  some  other  primary  disease. 

Chronic  Gastritis. — This  condition  may  be  dififerentiated  from  achlor- 
hydria haemorrhagica  gastrica,  though  the  latter  might  be  considered  an 
infective  gastric  catarrh  resulting  from  reflex  achlorhydria  with  infection. 
With  chronic  gastritis  there  is  not  the  peculiar  yellow  appearance  of  the 
contents  from  serum  exudation,  the  acidity  is  usually  somewhat  higher, 
and  combined  hydrochloric  acid  is  generally  present.  There  are  not  the 
excessive  numbers  of  bacteria,  and  occult  blood  is  usually  absent  and  not 
always  present  as  it  is  in  achlorhydria  haemorrhagica.  Chronic  gastritis 
is  not  a  reflex  from  another  primary  disease.^  ^ 

Prognosis. — In  the  cases  reported,  172  have  been  traced  as  to  the 

ultimate  results.     Sixty-one  have  entirely  recovered,  38  have  an  occasional 

complaint,  23  feel  comparatively  well,  9  were  moderately  improved,  in 

26  there  was  no  improvement,  4  became  worse,  and  11  died.     Among 

^  More  mucus  present  with  chronic  gastritis. 


274  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

those  who  died,  the  chief  primary  factor  were  pancreatitis,  nephritis, 
myocarditis,  and  pernicious  anemia. 

One  case  developed  carcinoma  of  the  stomach,  and  two  histories 
suggested  the  same  condition,  but  were  not  positively  confirmed. 

The  best  results  secured  were  in  those  operated  on  for  the  primary 
cause.  One  must  remember,  therefore,  the  possibiHty  of  gastric  ulcer  or 
carcinoma  developing  from  an  erosion  of  achlorhydria  haemorrhagica 
gastrica.  The  somewhat  rare  condition,  phlegmonous  gastritis,  the 
author  believes  may  occasionally  result  from  this  infected  type  of  achlor- 
hydria. The  cure  of  the  latter  may,  therefore,  be  prophylactic  against 
more  serious  conditions. 

Treatment. — The  primary  factor  upon  which  the  reflex  achlorhydria 
depends  should  be  determined  and  receive  appropriate  treatment.  The 
most  favorable  results  have  been  secured  when  this  has  proved  to  be  a 
surgical  condition  amenable  to  cure,  such  as  appendicitis,  gall-stones,  etc. 
Complete  restoration  of  the  hydrochloric  acid,  disappearance  of  the  occult 
blood  from  the  gastric  contents,  and  cure  of  the  gastric  symptoms  have 
resulted.  If  the  primary  cause  be  a  medical  condition,  it  should  also 
receive  treatment. 

The  secondary  condition,  achlorhydria  haemorrhagica  gastrica,  should 
be  properly  cared  for. 

Diet. — The  diet  is  important,  milk  with  lime-water  or  peptonized, 
koumiss,  bacillac,  fermillac,  lactone  buttermilk,  gruels,  broths,  and  raw 
eggs  beaten  up  with  milk  are  indicated  during  the  first  few  weeks.  Soma- 
tose,  plasmon,  or  tropon  can  be  added  to  the  gruels  or  milk.  It  is  pref- 
erable at  first  to  give  four  or  five  small  feedings  daily.  Later,  soft-boiled 
eggs,  mashed  pa  to  toes,  thickened  gruels,  rice  well  boiled  and  passed 
through  a  colander,  scraped  raw  beef,  stale  toasted  bread,  etc.,  may  be 
added.  Fats,  such  as  plenty  of  butter  and  cream,  are  necessary  to  increase 
the  weight.  Later  there  may  be  a  gradual  return  to  full  diet  of  a  simple 
type.  Care  should  be  exercised  for  some  time.  Acids  cause  pain  from  the 
erosions.  Pickles,  spices,  alcohol,  and  all  irritating  material  should  be 
avoided.  Smoking  should  be  interdicted.  Lobster,  cucumbers,  corn, 
sausage,  hot  breads,  and  all  indigestible  food  should  be  avoided  until 
complete  recovery. 

Medication. — Alkalis  combined  with  bismuth  give  the  best  result. 
They  dissolve  or  remove  the  mucus  and  the  bismuth  coats  the  erosions. 
One  can  combine  soda  bicarbonate,  15  grains  to  H  dram  (1.0-2.0),  with 
equal  doses  of  bismuth  subnitrate,  given  stirred  up  in  a  half  glass  of  water 
t.i.d.  before  meals.  The  addition  of  olive  oil  given  J^  to  i  ounce  before 
the  other  two  meals  helps  nutrition,  coats  the  erosions,  and  aids  bowel 
action.  Tonics  are  indicated,  such  as  iron,  tropon,  or  any  good  prep- 
aration particularly  with  arsenic  in  combination.  In  view  of  the  fre- 
quent presence  of  colon  bacilli  in  the  stomach,  particularly  when  the  achlor- 
hydria is  secondary  to  appendicitis  or  gall-bladder  disease,  treatment  for 
colon  bacillus  infection,  the  writer  believes,  is  indicated.  The  urine  should 
be  examined  also  for  these  bacilli.  The  writer  advocates  the  administra- 
tion of  hexamethylenamin,  30  grains  to  i  dram  (2.0-4.0)  daily,  in  lo-grain 
doses,  combined  with  sodium  benzoate,  equal  quantities,  for  achlorhydria 


ACHLORHYDRIA    HEMORRHAGICA   GASTRICA  275 

haemorrhagica  gastrica.  Vomiting  is  relieved  by  oxalate  of  cerium,  etc. 
Lavage  affords  most  rapid  relief. 

Lavage. — ^Lavage  affords  great  relief  to  the  pain  and  clears  off  the 
mucus.  Mild  antiseptics  should  be  added  on  account  of  the  bacterial 
infection.  Acetozone,  i  :  1000  in  normal  salt  solution,  once  daily  is  useful, 
and  if  there  is  much  pus  it  could  be  employed  more  frequently,  say  twice 
a  day.  In  some  cases  substituting  lavage  twice  a  week  with  silver 
nitrate  solution,  i :  5000  to  i :  2000,  followed  by  washing  with  normal 
saline  solution,  or  protargol  or  argyrol  i  :  2500-1  :  1500;  on  the  other  days 
use  acetozone.  Tincture  of  belladonna  in  lo-drop  doses  several  times 
daily,  in  some  cases  pushed  to  physiologic  symptoms,  is  of  value  to  relieve 
the  pain  from  the  erosions  and  also  for  pylorospasm. 

In  addition,  one  can  employ  for  the  pain  hot  fomentations  or  dry  heat 
over  the  epigastrium.  Orthoform  hydrochlorid  or  anesthesin  5  to  j^ 
grains  (0.3-0.5)  t.i.d.  can  be  given  for  pain.  Lavage  also  affords  relief. 
Cocain  should  never  be  used.  Opiates  should  be  avoided  unless  all  other 
means  fail,  and  should  only  be  given  under  the  immediate  direction  of 
the  physician,  first,  codein,  H  to  K  grain  (0.008-0.032),  or,  as  a  last 
resort,  morphin,  H  to  K  grain  (0.008-0.016),  by  h)T)odermic. 

Constipation  or  diarrhea  should  receive  appropriate  treatment. 


CHAPTER  XII 

HEMATEMESIS-ULCER    OF    THE     STOMACH— EXULCERATIO 
SIMPLEX— ACUTE  AND  CHRONIC  EROSIONS— PERI- 
GASTRITIS AND  PERIGASTRIC  ADHESIONS 

GASTRIC  HEMORRHAGE 

Vomiting  of  blood  cannot  be  considered  to  be  a  proof  of  gastric 
"hemorrhage,  as  it  may  come  from  the  esophagus,  nose,  or  mouth,  or  be 
coughed  up  and  swallowed. 

On  the  other  hand,  gastric  hemorrhage  may  occur,  and  the  blood  only 
appear  in  the  stools. 

The  causes  of  gastric  hemorrhage  may  be  classified  as  follows: 

1.  Trauma  over  the  stomach;  injuries  to  the  mucous  membrane  from 
foreign  bodies,  as  bones  or  needles;  damage  from  the  stomach-tube, 
mineral  acids,  or  caustic  alkalis. 

2.  Thrombosis  or  embolism  of  the  vessels;  aneurysm;  varicosities; 
atheroma  of  a  vessel,  or  fatty  degeneration, 

3.  Venous  stasis  due  to  cirrhosis  of  the  liver;  tumors  of  the  liver; 
pylephlebitis;  compression  of  the  vena  cava. 

In  case  of  cirrhosis  the  hemorrhage  is  from  the  mucous  membrane  or 
from  esophageal  varices. 

4.  Lesions  of  the  heart  or  lungs,  causing  stasis  in  the  vena  cava. 

5.  Constitutional  diseases,  as  leukemia;  pseudoleukemia;  pernicious 
anemia;  hemophilia;  scurvy;  purpura;  melena  (morbus  maculosus 
neonatorum). 

6.  Menstrual  type,  when  amenorrhea  is  present. 

7.  Lesions  of  the  central  nervous  system  (brain  or  spinal  cord). 

8.  Hysteria. 

9.  Ulcer  of  the  stomach  and  carcinoma. 

10.  Acute  infectious  diseases,  as  yellow  fever,  scarlet  fever,  measles, 
small-pox,  pneumonia,  etc. 

11.  Weil's  disease  (epidemic  jaundice);  malignant  jaundice  (acute 
yellow  atrophy) ;  diseases  of  the  pancreas,  acute  and  chronic. 

12.  Banti's  disease  with  enlarged  spleen,  anemia,  ascites,  cirrhosis  of 
the  liver,  gastro-intestinal  hemorrhage,  etc. 

13.  Phosphorus-poisoning. 

14.  Acute  jaundice  with  hemorrhage,  following  operation. 

15.  Erosions — postoperative  hematemesis  due  to  these;  the  French 
describe  them  after  appendicitis  as  vomito-negro-appendiculaire. 

16.  Exulceratio  simplex  (Dieulafoy),  or  superficial  ulceration  of  the 
stomach. 

17.  Achlorhydria  haemorrhagica  gastrica;  hematemesis  from  the 
erosions  has  occasionally  been  reported.     It  is,  however,  rare. 

276 


ULCER    OF    THE    STOMACH  277 

18.  Arteriosclerosis  with  high  tension,  gastric  hemorrhage  which  may 
take  the  place  of  cerebral  hemorrhage. 

As  it  is  the  general' tendency  to  impute  cases  of  gastric  hemorrhage 
chiefly  to  ulcer  or  cancer,  it  seemed  desirable  to  classify  all  causes. 

Symptoms. — The  chief  symptoms  are  hematemesis  and  melena. 
Acute  anemia  develops  if  much  blood  is  lost;  the  patient  feels  dizzy  and 
weak  and  faints  easily.  The  sight  is  blurred,  pulse  rapid  and  feeble,  and 
extremities  cold;  rarely  convulsions  and  death  follow.  Nausea  and  vomit- 
ing occur.  The  blood  may  be  dark  in  color  or  coffee  ground  in  appearance, 
or  light  if  in  a  large  amount.  An  evanescent  rise  of  temperature  may 
occur  after  the  hemorrhage. 

At  times  the  symptoms  may  take  place  with  no  hematemesis  and 
nothing  definite  visible  in  the  stool,  when  Weber's  or  the  benzidin  test 
may  be  necessary  to  determine  the  presence  of  occult  blood. 

Prognosis. — The  prognosis  is  rarely  fatal  from  the  hemorrhage  itself, 
but  depends  on  the  primary  disease. 

Treatment. — A  hypodermic  of  morphin,  J^  grain  (0.016),  and  locally 
the  ice-bag;  extract  ergot,  K  dram  (2.0)  in  solution  by  hypodermic,  or 
ernutin,  5  minims  (0.3)  by  hypodermic,  and  in  addition  gelatin  10  per  cent, 
solution,  or  Tremoliere's  solution  gelatin,  5  per  cent,  with  calcium  chlorid, 
2  per  cent.  These  gelatin  preparations  should  be  given  from  2  drams  to 
I  ounce  (8.0-30.0)  every  half  hour  to  an  hour  by  mouth. 

Tannic  acid,  15  grains  (0.33),  or  lactate  or  chlorid  calcium,  15  grains 
(i.o),  should  be  given  in  solution  (water  6  ounces  or  200  c.c.)  by  rectum; 
Tannic  acid,  5  grains,  may  be  given  by  mouth  in  capsule.  Lactate  of 
strontium  or  magnesium,  15  to  30  grains  (1.0-2.0)  in  2  ounces  (60  c.c.) 
of  water,  can  also  be  administered  by  hypodermic. 

Adrenalin  chlorid  (i  :  1000);  5  to  10  drops  (0.291-0.582  c.c),  by  mouth 
or  hypodermic  is  recommended,  but  it  at  times  too  rapidly  increases  pulse 
tension,  especially  if  given  hypodermically.  By  mouth,  sterile  horse 
serum,  30-80  c.c.  daily,  or  human  blood  serum,  20  c.c,  by  hypodermic  are 
of  value. 

Hypodermoclysis  or  the  rectal  injection  of  normal  saline  at  i2o"'F. 
are  useful.  Proctoclysis  is  of  value.  Ice-water  lavage  in  rare  instances 
may  be  necessary,  to  which  add  adrenalin  10  drops,  lactate  calcium  3ss 
and  5i  of  10  per  cent,  gelatin.  Stimulants,  such  as  strychnin,  }4o  grain 
(0.00108),  or  camphorated  oil,  7).^  grains  (0.5),  camphor  in  20  minims  (1.3) 
of  sterile  almond  oil,  by  hypodermic,  may  be  required. 

ULCER  OF  THE  STOMACH 

(Synonyms. — Ulcus  Ventriculi  (Simplex);  Peptic  Ulcer;  Ulcus  Ventricufi  Rotundum; 
Perforating  Gastric  Ulcer;  Cruveilhier's  Disease) 

Ulcer  of  the  stomach  is  characterized  by  a  destruction  of  the  mucous 
membrane  of  the  stomach  varying  in  degree,  exhibiting  no  tendency  to 
heal,  and  in  typic  cases  attended  with  gastric  symptoms  associated  with 
pain,  vomiting,  and  hematemesis.  It  was  first  described  by  Cruveilhier 
in  1829. 

Etiology. — Postmortem  and  Geographic  Distribution. — Brinton  found 
evidences  of  gastric  ulcer  in  5  per  cent,  of  persons  dying  from  all  causes, 


278  DISEASES    OF   THE    STOMACH    AND    INTESTINES 

and  most  frequently  in  London  and  on  the  Continent.  Others  claim 
that  gastric  ulcer  is  found  in  at  least  10  per  cent,  of  cases.  Gerhardt 
notes  its  frequent  occurrence  in  Thuringia,  and  Von  Sohlern  its  rarity  in 
Russia,  the  Rhine  region,  and  in  the  Bavarian  Alps,  believing  this  to  be 
due  to  the  vegetarian  diet  (rich  in  potassium  salts)  in  these  countries. 
This  theory  lacks  scientific  confirmation. 

Sex. — Gastric  ulcer  occurs  more  frequently  in  women  than  in  men. 
Welch  places  it  at  60  per  cent,  in  women  and  40  per  cent,  in  men,  while 
Brinton  believes  it  twice  as  frequent  in  women. 

Frequency. — The  Mayos  and  Moynihan  hold  that  duodenal  ulcer  is 
more  frequent  than  gastric  ulcer.  Personally  I  have  found  gastric  ulcer 
a  trifle  in  excess  of  duodenal.     Observers  probably  vary  slightly. 

Age. — Cases  have  been  reported  in  children  under  ten  years.  It 
occurs  most  frequently  between  twenty  and  forty  years  in  females,  and 
in  males  quite  often  between  forty  and  fifty.  Ewald  places  the  highest 
mortality  between  forty  and  sixty.     It  may  occur  in  old  people. 

Occupation. — Cooks,  tailors,  shoemakers,  metal  workers,  and  porcelain 
makers  are  most  liable  to  this  disease,  but  it  seems  a  matter  merely  of 
coincidence.  It  was  believed  that  swallowing  of  overhot  food  by  cooks, 
the  ingestion  of  metal  and  glass  particles  by  the  metal  and  glass  workers 
and  the  cramped  position  with  pressure  occupied  by  tailors  and  shoe- 
makers were  causes. 

Etiology  of  Gastric  Ulcer. — Many  theories  have  been  advanced  as  to 
the  cause  of  gastric  ulcer,  and  C.  F.  Martin^  describes,  in  an  article  on 
gastric  and  duodenal  ulcers,  some  thirty-six  causes.  If  one  investigate 
the  writings  of  various  authors,  this  list  can  be  considerably  increased. 

Traumatism. — Simple  trauma  probably  cannot  produce  gastric  ulcer 
unless  other  conditions  are  associated.  Blows,  falls,  and  the  swallowing 
of  foreign  bodies,  such  as  knives  by  jugglers,  etc.,  have  produced  severe 
damage  to  the  mucosa  of  the  stomach  and  marked  hemorrhage,  without 
the  ultimate  production  of  ulcer.  Griffini  and  Vassale  have  resected  or 
burned  out  portions  of  the  mucosa  of  the  stomachs  of  animals  and  perfect 
healing  has  taken  place,  with  no  ulceration.  Traumatism  may  be  a  factor, 
as  is  shown  in  the  following  case  of  mine:  Girl,  aged  twenty-two,  with  no 
gastric  symptoms,  was  thrown  from  a  trolley  car,  striking  on  the  epigastric 
region.  Pain  and  tenderness  were  present  at  this  point  and  gastric  symp- 
toms developed.  There  was  no  visible  hemorrhage,  but  pain  and  symp- 
toms continued  for  six  weeks,  apparently  of  hyperchlorhydria,  but  local 
tenderness  persisted  at  the  point  of  injury.  The  patient  then  had  a 
sudden  gastric  hemorrhage  of  severe  type  and  the  ultimate  course  was  of 
ulcer  of  the  stomach.  Cure  resulted  in  eight  months,  the  case  being 
observed  for  several  years  subsequently,  with  no  recurrence.  This  girl 
wa&  anemic  before  the  accident  and  probably  hyperchlorhydria  was 
present,  though  no  symptoms  were  complained  of.  A  hematoma  was,  I 
believe,  produced  in  the  stomach  wall,  interfering  with  its  nutrition,  and 
the  other  conditions  favored  ulcer  development.  The  patient  also  had  a 
hematoma  of  the  thigh  from  the  same  accident.  Traumatism  under 
such  conditions  may  be  a  factor. 

*  Osier's  Modern  Medicine,  v,  p.  175. 


ULCER    OF    THE    STOMACH  279 

Anemia  and  chlorosis  may  predispose  to  ulcer,  and  Riegel  and  Charles 
Stockton  have  shown  that  hyperchlorhydria  frequently  accompanies  these 
conditions,  and  that  it  has  an  influence  in  the  prevention  of  the  cure  of 
ulcer  or  even  in  its  production.  Experiments  on  animals  have  been  per- 
formed for  the  purpose  of  studying  the  etiology  of  ulcer.  Quincke  and 
Daettwyler  made  animals  anemic  by  venesection  and  produced  lesions 
in  the  gastric  mucosa.  Section  of  the  spirial  cord,  with  the  introduction 
of  one-half  of  i  per  cent,  hydrochloric  acid  solution  in  the  stomach  of  a  dog, 
has  produced  ulceration  (Koch  and  Ewald).  It  has  occurred  after  injury 
to  the  anterior  corpora  quadrigemina.  Hypodermic  injections  of  pyrodin 
with  the  production  of  anemia  with  and  without  bilateral  section  of  the 
vagus  nerve  has  been  practised  on  dogs  by  Crescinome^  and  Anglesio,  with 
resulting  gastric  ulcers.     The  vagus  resection  aggravated  the  lesions. 

Halliburton^  states  that  just  as  poisons  from  without  stimulate  the 
cells  to  produce  antitoxins,  so  harmful  substances  produced  within  the 
body  are  provided  with  antisub stances  capable  of  neutralizing  their  effects. 
For  this  reason  the  blood  does  not  clot  within  the  blood-vessels,  and  Wein- 
land  recently  has  shown  that  there  is  formed  in  the  gastric  mucosa  an 
antibody,  an  antipepsin,  which  opposes  the  digestive  action  of  the  acid 
gastric  juice.  If  the  antibody  is  deficient  in  a  certain  area,  this  umpro- 
tected  region  is  readily  injured  by  the  gastric  juice.  The  same  writer 
holds  that  the  intestinal  epithelium  forms  an  antitrypsin.  The  principle 
just  referred  to  has  been  lately  put  into  practical  use.  E.  C.  Hort' 
maintains  that  gastric  ulcer  is  not  a  disease  sui  generis,  but  merely  a  local 
expression  of  a  general  dyscrasia  caused  by  the  presence  in  the  blood  of 
cytolitics  for  the  gastric  epithelium;  he  attempts  by  this  treatment  to 
reestablish  a  condition  of  immunity  of  the  gastric  mucosa  to  the  action  of 
gastrolytic  toxins  and  enzymes,  which  first  cause  and  then  render  per- 
manent the  ulcers.  He  employs  fresh  normal  horse  serum,  given  by 
mouth.  The  method  and  dosage  are  described  later.  Rosenow  has 
produced  gastric  ulcer  by  the  injection  of  diphtheria  antitoxin.  Botton* 
has  produced  gastric  ulcer  in  animals  by  injecting  the  macerated  gastric 
mucosa  of  other  animals  and  of  animals  of  other  species.  Epinephrin, 
liquor  formaldehyd,  nicotin,  silver  nitrate,  etc.,  by  injection  into  the 
walls  of  the  stomach  and  injection  of  bacteria  into  the  gastric  artery 
have  produced  gastric  ulcer,  and  the  association  of  mouth  and  tonsillar 
infections  with  ulcer  of  the  stomach  has  been  noted.  Rosenow*  has 
demonstrated  experimentally  that  ulcer  of  the  stomach  has  followed 
intravenous  injection  of  organisms  isolated  from  rheumatism  especially 
after  passage  through  animals.  One  strain  originally  a  pneumococcus 
isolated  from  the  blood  in  pneumonia  after  being  passed  through  twenty 
rabbits  had  been  transformed  into  a  hemolytic  streptococcus. 

The  neurotrophic  theory  has  been  held  by  some.  Stockton  believes 
that  nerve  perturbation  analogous  to  herpes  may  be  a  factor;  and  de  la 

*  Riforma  Medica,  Nov.  21,  1914. 

2  The  Lancet  (London),  Dec.  21,  1907;  Ibid.,  Feb.  15,  1908;  Brit.  Med.  Jour.. 
Oct.  10,  1909;  Ibid.,  Jan.  5,  1910,  p.  75. 
'  Kirkes'  Physiology,  20th  Ed.,  p.  488. 

*  The  Lancet,  1908,  i,  pp.  1330-1333. 

'  Journal  A.  M.  A.,  April  19,  1913,  and  Nov.  29,  1913. 


28o  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Verdora  produced  ulcer  and  hyperchlorhydria  by  injecting  alcohol  into 
the  splanchnic  and  celiac  plexus  of  a  dog.  Section  of  the  vagi  below  the 
diaphragm  has  caused  ulceration  of  the  gastric  mucosa.  These  experi- 
ments suggest  that  the  nervous  system  may  be  a  factor, 

Kaufmann  believes  that  lack  of  gastric  mucus  (amyxorrhoea  gastrica) 
has  a  relation  to  hyperacidity  and  gastric  ulcer. 

Silberman  introduced  substances  into  the  blood  producing  hemolysis 
(hemoglobinemia)  with  resulting  anemia,  and  found  that  defects  of  the 
mucosa  healed  tardily.  Tiirck  has  produced  gastric  ulcer  by  feeding 
dogs  with  pure  cultures  of  the  bacterium  coli  commune.  R,  T.  Morris 
holds  that  gastric  ulcer  may  result  secondarily  from  gall-bladder  or  from 
appendical  infection  with  the  colon  bacillus,  or  that  toxins  may  cause 
vascular  disturbances  in  the  terminal  arteries  with  ulcer  as  a  result.  Pilcher 
believes  it  may  develop  from  an  infected  erosion  from  achlorhydria 
haemorrhagica  gastrica.  The  Mayos  have  called  to  our  attention  the 
close  association  between  gall-bladder  infection,  appendicitis  and  ga.stric 
ulcer.  The  writer  has  had  several  patients  in  whom  gastric  ulcers  were  ap- 
parently secondary  to  an  infected  appendix  or  gall-bladder.  Friedman  and 
Hamburger'  have  experimentally  produced  chronic  gastric  ulcer  in  ani- 
mals, by  partially  obstructing  the  pylorus  by  surrounding  it  with  a  silk 
ligature  and  acute  ulcers  were  first  produced  by  injecting  silver  nitrate 
into  the  submucosa.  The  ulcers  in  some  cases  changed  into  the  chronic 
type.  Rosenow,^  "after  further  experimentation,  has  produced  gastric 
ulcers  by  streptococci  injections  secured  from  gastric  ulcers  and  believes 
there  is  a  special  strain  of  bacteria,  and  Carlson  has  observed  in  dogs  in 
whom  experimental  parathyroid  tetany  had  been  produced,  in  75  per  cent, 
of  cases  showed  ulcers  in  the  duodenum  and  pylorus.  Intravenous  injec- 
tion of  staphylococci,  pneumococci,  B.  coli,  etc.,  have  produced  acute 
gastric  ulcers.  Vagotonia  with  spastic  contraction  of  the  musculature  of 
the  stomach  resulting  in  erosions,  in  combination  with  hyperacidity  is 
believed  by  some  to  be  a  factor.  It  is  known  that  burns  of  the  abdomen 
may  produce  gastric  ulcer,  though  usually  the  duodenum  is  affected. 

Pavy  held  the  theory  of  diminished  alkalinity  of  the  blood,  but  this 
can  hardly  be  accepted.  Erosions  have  been  considered  by  some,  notably 
Bassler,  to  be  the  cause  of  ulcers,  but  Langerhans  opposed  this  from  his 
experience  in  autopsies,  and  Einhorn  claims  that  gastric  erosions  are  a 
clinical  entity  and  that  ulcer  does  not  result.  The  Mayos  report  two  cases 
substantiating  Pilcher's  view.  We  know  that  autodigestion  of  the  gastric 
mucosa  occurs  after  death.  The  effect,  therefore,  of  circulatory  disturb- 
ances of  the  blood-vessels  of  the  stomach  in  the  development  of  ulceration 
is  important. 

Virchow  first  suggested  that  ulceration  may  result  from  the  plugging 
of  a  nutrient  artery  to  part  of  the  mucosa  by  a  thrombus  or  embolus,  and 
that  the  infarction  is  destroyed  by  the  gastric  juice.  Panum  supported 
this  view  by  producing  infarcts  and  ulcers  of  the  stomach  in  a  dog  by  in- 
jecting an  emulsion  of  wax  into  the  femoral  artery.  Occlusion  of  the  por- 
tal vein  or  of  some  of  the  large  veins  of  the  stomach  may  cause  gastric  ulcer. 

*  Journal  A.  M.  A.,  Aug.  i,  1914. 

^Rosenow,  "Elective  Localization  of  Streptococci,"  Journal  A.  M.  A.,  Nov.  13,  1915. 


ULCER    OF    THE    STOMACH  •  281 

Injection  of  chromate  of  lead  into  the  gastric  and  splenic  arteries 
(Cohnheim)  has  produced  ulcer.  Talma,  by  increasing  the  tension  of  the 
gastric  wall  by  ligating  the  orifices  of  the  stomach,  has  brought  about 
ulceration.  Artificial  anemia  by  faradization  of  the  stomach  has  caused 
ulcer.  Local  interference  with  the  circulation,  with  resulting  necrosis, 
associated  with  hyperchlorhydria  and  changes  in  the  blood  and  deficiency^ 
of  antibodies  are  probably  the  most  frequent  causes. 

Hyperchlorhydria  is  present  in  about  95  per  cent,  of  the  acute  cases, 
but  occasionally  there  is  subacidity  or  achylia  gastrica,  as  reported  by 
Einhorn  and  others.  Moreover,  Spriggs^  has  demonstrated  that  the 
total  acid  content  may  be  increased  by  hypersecretion,  by  interference  with 
the  motility  of  the  stomach  due  to  pyloric  spasm,  for  example,  and  by  the 
production  of  organic  acids.  This  statement  as  to  hyperchlorhydria  in 
gastric  ulcer  refers,  of  course,  chiefly  to  the  acute  cases,  especially  in  the 
younger  subjects.  On  the  other  hand,  the  reports  from  Mayo's  cases 
show  that  of  75  per  cent,  of  the  cases  that  come  to  the  operating- table, 
chiefly  chronic  cases,  many  of  the  patients  do  not  show  the  high  degree 
of  acidity  as  is  commonly  supposed.  Thus,  in  250  cases  of  gastric  or 
duodenal  ulcer.' 

Free  HCl        Below  normal  Normal  Above  normal  Absent 

23  cases.  102  cases.  112  cases.    .  13  cases. 

I  have  recently  seen  a  case  with  very  low  acidity  (Connors'  case). 
Frequent  gastric  analysis  showed  free  HCl  trace  or  absent;  lactic  acid 
present;  microscopic  pus  and  occult  blood.  Multiple  ulcers  (non-malgi- 
nant)  were  found  by  John  Connors  at  operation.  Probably  gastric  ulcer  is 
not  always  produced  by  the  same  factors,  and  several  of  the  theories 
described  may  apply.  Hyperchlorhydria  undoubtedly  has  a  bearing  on 
many  cases,  and  frequently  anemia,  or  chlorosis,  with  local  interference 
with  the  gastric  circulation.  Colon  bacilli,  or  infection  from  the  appendix 
or  gall-bladder  are  responsible  in  some  cases.  It  is  now  deemed  advisable 
to  inspect  the  gall-bladder  and  appendix  (generally  removing  the  latter), 
when  operating  on  gastric  or  duodenal  ulcer. 

Morbid  Anatomy. — The  peptic  ulcer  is  found  in  the  regions  exposed  to 
the  gastric  juice,  in  the  stomach,  lowest  part  of  the  esophagus,  and  upper 
duodenum.  It  is  round  or  oval,  occasionally  oblong;  is  funnel  shaped,  the 
upper  part  being  the  larger;  is  of  variable  depth,  its  floor  being  formed  by 
the  submucosa,  muscular  tissue,  serosa,  or  by  adjacent  adherent  organs. 
The  acute  ulcer  is  usually  small,  punched  out,  with  clean  cut  edges  and  a 
smooth  floor,  with  no  thickening  of  the  peritoneal  coat;  occasionally  the 
floor  may  be  covered  with  a  thick  green  or  brown  mucus  (Fig.  184). 

The  chronic  ulcer  is  of  larger  size,  with  callous  margins,  and  the  border 
may  be  sinuous.  It  is  often  markedly  indurated,  so  if  situated  at  the 
pylorus  it  may  feel  like  a  tumor  on  palpation. 

Embolism  or  endarteritis  of  the  artery  supplying  the  ulcerated  region 
has  been  found,  or  a  small  aneurysm  on  the  floor  of  the  ulcer. 

Microscopically. — The  ducts  of  the  glands  are  cut  off  toward  the  base, 

'  Bacterial  infection  is  probably  a  factor. 

*  Brit.  Med.  Jour.,  May  21,  1910. 

'  New  York  Med  Jour.,  Sept,  4,  1909,  Graham  and  Guthrie. 


282 


DISEASES    OF   THE    STOMACH    AND   INTESTINES 


being  eaten  away  or  digested  up  to  where  the  tissue  offers  sufficient  resist- 
ant power  to  the  gastric  juice. 

Healing  occurs  by  proliferation  of  the  connective  and  glandular  tissue 
near  the  margin  of  the  gland.  As  the  connective  tissue  contracts  the  pro- 
liferation of  the  glands  is  stopped.  If  the  stomach  wall  is  adherent  to  an 
adjacent  organ  and  the  ulcer  perforates,  the  neighboring  tissue  may  grow 
into  the  hole  and  unite  with  the  connective  tissue  growing  from  within. 
Muscle-fibers  do  not  regenerate.  This  is  true  of  the  large  deep  ulcers. 
The  mucosa  and  muscularis  roll  in  and  ahdere  to  the  adjacent  organ. 
There  is  further  proliferation  of  tissue  casued  by  irritation  of  the  gastric 
juice,  and  the  latter  may  cause  erosion  of  vessels. 


Fig.  184. — Gastric  ulcer,  acute:  i,  Glandular  layer;  2,  submucosa;  3,  muscular 
layer;  4,  peritoneum.  (From  Bassler's  "Diseases  of  the  Stomach  and  Upper  Ali- 
mentary Tract."     Copyright,  1910,  by  F.  \.  Davis  Company.) 


The  rest  of  the  mucous  membrane  of  the  stomach,  as  a  rule,  remains 
normal. 

Extent  of  the  Ulcer. — It  may  vary  from  the  size  of  a  pea  to  a  diameter  of 
5  or  6  inches;  the  average  being  from  a  5-cent  piece  to  a  25-cent  piece. 
Peabody  reports  one  measuring  19  by  10  cm. 

Location. — It  is  commonly  situated  on  the  posterior  wall  of  the  pyloric 
end  of  the  stomach,  at  or  near  the  lesser  curvature.  Welch  states  that 
out  of  793  cases,  288  were  in  the  lesser  curvature,  95  at  the  pylorus,  96  on 
the  anterior  wall,  50  at  the  cardia,  29  at  the  fundus,  and  27  on  the  greater 
curvature.     Other  statistics  are  given. 

Number. — In  about  80  per  cent,  of  cases  i  ulcer  is  found;  in  a  trifle 
over  one-half  the  remainder,  2  ulcers;  in  the  balance,  3  to  5  ulcers;  Osier 


ULCER   OF    THE    STOMACH  283 

reports  34  ulcers  in  i  case,  and  Lange  i  in  which  he  could  not  count 
them. 

Progress  of  the  Ulcer. — i.  Cicatrization  may  occur,  with  formation 
of  a  connective-tissue  scar,  which  tends  to  depress  and  contract.     Depend- 
ing on  its  location,  it  may  cause  stricture  of  the  pylorus,  esophagus,  or  an 
hour-glass  stomach.     In  other  situations  it  may  produce  no  trouble. 
2.  Progressive  necrosis  may  take  place  and  there  may  result: 

(a)  Erosion  of  a  blood-vessel  with  severe  or  occasionally  fatal  hemor- 
rhage from  perforation  of  a  large  vessel,  such  as  the  gastric,  hepatic,  or 
splenic  artery,  portal  vein,  etc. 

(b)  Adhesions  to  neighboring  organs  or  various  perforations.  The 
stomach  may  become  adherent  to  the  liver,  gall-bladder,  spleen,  pancreas, 
or  intestines,  and  there  may  be  perforation  into  these  organs. 

If  the  ulcer  is  on  the  anterior  surface,  then  direct  perforation  and 
general  peritonitis  may  follow. 

There  is  sometimes  a  circumscribed  peritonitis  when  adhesions  form 
with  other  organs,  and  a  local  abscess,  which  may  later  perforate  into  the 
peritoneal  cavity. 

The  ulcer  may  perforate  into  the  lesser  peritoneal  cavity  and  cause 
subphrenic  abscess;  the  diaphragm  may  be  perforated  and  a  communica- 
tion formed  with  the  pleura,  lungs,  pericardium,  and  even  with  the  left 
ventricle;  or,  rarely,  an  emphysema  of  the  subperitoneal  tissue  occurs, 
which  may  pass  into  the  posterior  mediastinum;  or  adhesions  may  form 
and  a  perforation  of  the  anterior  abdominal  wall  take  place;  or  general 
emphysema  of  the  subcutaneous  tissues  may  rarely  result. 

In  cases  with  adhesions  to  adjacent  organs,  with  or  without  abscess, 
localized  growing  tumors,  hard  in  consistency,  may  be  formed,  and  Ger- 
hardt  notes  the  possibility  of  mistaking  these  for  carcinoma,  but  the  his- 
tory and  gastric  analysis  determine  the  diagnosis. 

Symptoms. — Some  cases  present  typic  symptoms,  in  which  event  the 
diagnosis  is  easy;  others  suffer  apparently  from  a  simple  hyperchlorhydria 
for  a  long  period  of  time,  with  no  special  symptoms  pointing  to  ulcer; 
while  in  others  the  condition  is  latent. 

In  the  latent  cases  the  patient  is  sometimes  apparently  perfectly  well, 
when  there  will  suddenly  develop  hematemesis  or  symptoms  of  perforative 
peritonitis.  Others  may  not  vomit,  but  suddenly  turn  faint  and  weak, 
become  pale  with  a  feeble  pulse,  presenting  the  symptoms  of  internal  hemor- 
rhage. Examination  of  the  stool  for  occult  (concealed)  hemorrhage  by 
Weber's,  the  aloin,  or  the  benzidin  test  is  a  valuable  aid. 

Cases  Simulating  Hyperchlorhydria. — Kaufmann,^  of  New  York,  has 
suggested  that  in  cases  of  hyperchlorhydria  not  yielding  to  treatment 
and  in  whom  the  pain  is  of  a  gnawing  or  tearing  character  the  suspicion 
of  ulcer  is -justified.  This  is  undoubtedly  true,  and  repeated  examina- 
tions of  the  gastric  contents  and  stool  for  blood  or  occult  blood  are  indi- 
cated. Pus  in  the  gastric  contents  is  significant.  This  is  determined  by 
the  microscope. 

Typical  Case. — As  a  rule,  the  symptoms  of  gastric  ulcer  develop  slowly, 
and  are  as  follows:  at  first  a  feeling  of  fulness  and  pressure  aftev"  eating; 
'  New  York  Med.  Jour,  and  Philadelphia  Med.  Jour.,  March  11,  1905. 


284  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

gradually  increasing  to  pain  in  the  epigastrium,  which  may  become  so 
severe  that  the  patient  is  afraid  to  eat.  Nausea,  regurgitation,  or  vomit- 
ing may  occur  early. 

Pain  occurs  generally  a  few  minutes  after  eating,  though  sometimes  one- 
half  to  one  hour  later,  and  persisting  during  digestion.  If  there  is  hyper- 
acidity, milk  or  the  white  of  eggs  (raw)  or  soda  bicarbonate  may  tempo- 
rarily relieve  the  pain.  Liquid  nourishment  causes  the  least  disturbance. 
Coarse  substances,  hot  ingesta,  and  large  quantities  of  food  increase  it. 
It  is  of  a  burning  or  gnawing  character.  Epigastric  pain  is  increased  on 
pressure  and  the  sensitive  point  is  usually  circumscribed. 

A  few  weeks  later  dorsal  pain  begins,  gnawing  in  character,  lying  to  the 
left  of  the  spine,  between  the  eighth  and  tenth  vertebrae,  alternating  with 
the  epigastric  pain;  at  times  there  is  sensitiveness  on  pressure  in  this 
region. 

The  epigastric  pain  is  not  continuous,  as  in  cancer,  but  there  are  periods 
of  relief.  Later,  vomiting  may  occur,  one  to  two  hours  after  meals,  of 
very  acid,  watery  material,  mixed  with  food;  emesis  generally  relieves  the 
pain;  occasionally  there  is  vomiting  late  at  night  or  early  in  the  morning 
if  gastrosuccorrhea  (hypersecretion)  is  associated  with  ulcer. 

Appetite  is  variable;  at  times  the  patient  desires  food,  but  fears  to  eat 
on  account  of  pain;  constipation  is  generally  marked;  amenorrhea  is  fre- 
quent in  women;  anemia  marked  in  many  cases. 

These  symptoms  continue,  then  hemorrhage  suddenly  occurs,  and  is 
visibly  present  in  one-third  to  one-half  the  cases,  and  in  a  very  large  per- 
centage when  occult  hemorrhage  is  included,  as  it  should  be.  W.  L.  Rod- 
man,^ holds  that  hemorrhage  is  a  marked  symptom  in  at  least  50  per  cent, 
of  all  cases,  and  if  the  gastric  contents  and  stools  were  carefully  examined 
macroscopically,  microscopically,  and  for  occult  blood  from  day  to  day, 
the  probabilities  are  that  blood  would  be  found  in  nearly  every  case.  With 
this  last  the  author  cordially  agrees. 

1.  Hemorrhage  may  be  occult,  no  vomiting  of  blood,  the  patient  turning 
pale  and  faint  and  in  a  cold  sweat,  and  on  the  next  day  there  are  tarry 
stools,  or  occult  blood  is  found  in  the  stool  by  Weber's  or  the  benzidin 
test.     Progressive  anemia  may  be  caused  by  small  repeated  hemorrhages. 

2.  The  patient  may  experience  a  sense  of  fulness  after  a  meal  and  be- 
come nauseated  and  restless;  then  hematemesis  occurs  in  large  amount, 
of  fluid  blood,  bright  red,  or  of  liver  color,  brown,  or  cofifee  grounds,  mixed 
with  food. 

Patient  may  feel  faint,  extremities  cold,  temperature  subnormal,  be- 
come collapsed,  and,  rarely,  even  die  from  hemorrhage.  Convulsions  and 
unconsciousness  may  precede  death.  Death  from  internal  hemorrhage 
can  occur  without  vomiting.  Blood  is  generally  passed  by  the  stools 
(melena),  black  and  tarry  in  color,  and  may  be  found  in  cases  with  no 
vomiting  or  in  latent  cases. 

Convulsions  from  cerebral  anemia,  or  hemiplegia  from  thrombosis,  or 
amaurosis  (possibly  permanent)  have  occurred.  A  temporary  rise  of 
temperature  may  follow  the  collapse.  Persistent  temperature  shows  com- 
plications. The  vomitus  in  acute  cases  usually  shows  hyperchlorhydria 
^  Jour.  Amer.  Med.  Assoc,  Sept.  15,  1906,  vol.  xlvii,  pp.  842-845. 


ULCER    OF    THE    STOMACH  285 

and  no  mucus.  With  chronic  ulcer  hyperchlorhydria  may  not  be  present. 
Tongue  is  clean  and  red,  rarely  coated. 

Often  there  are  remissions  and  exacerbations  of  the  symptoms,  and 
they  may  be  protracted;  from  no  apparent  cause  a  relapse  may  occur. 
With  an  unhealed  ulcer,  complications  or  perforation  may  occur  at  any 
time.  In  others,  ulcer  symptoms  may  disappear,  but  those  of  gastric 
dilatation,  adhesions,  etc.,  may  follow.  In  the  long  cases,  from  pain  and 
self-starvation,  marked  emaciation  takes  place,  the  sufTering  shows  in  the 
patient's  face,  but  there  is  not  the  sallow  appearance  of  cancer.  Tetanic 
attacks  complicating  chronic  ulcer  have  been  reported  by  Kaufmann.^ 

Pain. — The  epigastric  pain  usually  occurs  about  the  center  of  this 
region,  in  the  median  line,  just  below  the  tip  of  the  ensiform.  Occasionally 
it  is  more  to  the  right  or  left,  and  lies  in  a  circular  area  of  i  to  2  inches  in 
diameter.  Throbbing  and  pulsation  may  be  felt  in  the  epigastrium.  Pain 
is  usually  increased  on  pressure,  rearly  lessened.  It  is  injurious  to  fre- 
quently manipulate  the  painful  area  or  subject  it  to  marked  pressure. 
Singer^  calls  particular  attention  to  an  early  sign,  which  consists  of  dis- 
comfort or  pain  radiating  from  the  epigastrium  toward  the  costal  arches,  and 
thence  along  the  intercostal  nerve-roots  to  the  spine.  The  regularity  of 
the  appearance  of  this  pain  or  sense  of  discomfort,  especially  in  connection 
with  eating,  is  characteristic  even  when  there  is  scarcely  any  dyspeptic 
disturbance.  Testing  with  the  algesimeter  is  not  advisable.  Dorsal  pain 
comes  later. 

In  place  of  vomiting,  some  patients  regurgitate  acid  chyme,  with  pyro- 
sis, or  suffer  from  nausea. 

Motor  Function. — In  uncomplicated  cases  of  gastric  ulcer  this  is  in- 
creased. If  pyloric  stenosis  or  adhesions  complicate,  then  this  function 
is  interfered  with  (is  diminished)  and  retention  of  contents  occurs. 

Examination  of  the  Stomach  Contents. — If  the  diagnosis  of  ulcer  has 
been  positively  determined,  it  is  preferable  not  to  pass  the  tube.  If  there 
is  no  recent  hematemesis,  or  if  vomiting  is  excessive,  it  is  well  to  give  the 
test-meal  and  examine,  in  addition,  for  occult  blood.  For  example,  in 
order  to  combine  the  test  both  for  motor  function  and  chemic  analysis, 
the  night  before  a  meal  of  meat,  potatoes,  rice,  a  few  dried  raisins,  and 
some  chopped  spinach  can  be  given.  On  the  following  morning  the 
Ewald  test-breakfast  can  be  administered  and  the  contents  withdrawn  an 
hour  later.  The  presence  of  raisins,  rice,  and  spinach  withdrawn  at  this 
time  give  valuable  data.  The  Mayos^  wash  out  the  stomach  and  examine 
the  washings  for  food  remnants.  Moreover,  while  the  stomach-tube  is 
still  in  situ,  the  organ  is  artificially  distended  with  air  by  means  of  attach- 
ing a  Davidson's  syringe,  and  it  is  then  carefully  palpated  for  tumors  or 
ridges.  It  is  deflated  before  removal  of  the  tube.  If  hemorrhage  is  recent, 
the  writer  does  not  advise  this  method  of  inflation.  Lavage  after  the 
contents  are  removed  is  of  service,  as  it  checks  emesis,  and  thus  renders 
a  hemorrhage  less  liable  to  recur. 

If  the  patient  states  there  has  been  a  hemorrhage,  but  the  diagnosis  is 

^  Amer.  Jour.  Med.  Sci.,  April,  1904. 

^  Medizin  klinik,  Berlin,  Dec.  18,  1910,  vi,  No.  51. 

*  New  York  Med.  Jour.,  Sept.  4,  1909  (Graham  and  Guthrie). 


286  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

in  doubt,  the  tube  should  not  be  passed  earlier  than  ten  days  to  two  weeks 
after  the  history  of  hematemesis.  The  stool  can  be  examined  at  once  for 
occult  blood. 

If  vomiting  occurs,  the  vomitus  may  be  examined  by  preference,  but 
the  quantity  and  quality  of  the  food  and  time  of  ingestion  would  influence 
the  analytic  findings  and  might  lead  to  error.  Immediate  examination  of 
the  vomitus  and  stool  for  occult  blood  is  important. 

In  about  95  per  cent,  of  acute  uncomplicated  cases  of  ulcer,  hyper- 
chlorhydria  is  present;  the  total  acidity  is  high,  from  90+  to  150+,  and 
free  hydrochloric  acid. 50+  to  60+  or  even  90+,  and  there  is  no  mucus. 
Comparing  1000  cases  of  ulcers  of  the  stomach  and  duodenum  operated 
on  at  the  Mayos^  clinic  from  Jan.  i,  1907,  to  Dec.  31,  1912,  there  was  an 
average  total  acidity  in  these  cases  of  over  63,  more  than  five-sixths  of 
which  was  free.  In  a  similar  number  of  cases  of  carcinoma  of  the  stomach 
there  was  an  average  total  acidity  of  31,  of  which  one-third  was  free,  the 
more  advanced  the  case  the  lower  the  acidity  and  the  less  the  free  acid.  This 
shows  the  necessity  of  early  diagnosis  and  operation  before  the  typic  gastric 
contents  are  found.  In  fact,  it  has  been  demonstrated  that  a  differential 
diagnosis  between  a  chronic  gastric  ulcer  and  commencing  malignancy 
cannot  be  determined  even  by  the  ic-rays  and  only  by  pathologic  exami- 
nation, so  that  chronic  ulcer  should  be  considered  as  a  precancerous  stage 
and  should  be  treated  by  radical  operation  as  for  cancer.  The  writer 
finds  that  quite  a  number  of  his  cases  of  chronic  ulcer  do  not  show  high 
acidity.    These  are  chiefly  the  chronic  cases. 

Blood. — The  gastric  contents  should  be  examined  for  occult  blood. 

There  are  cases  of  subacidity,  or  even  of  achylia  gastrica,  with  ulcer. 

The  Absence  of  Hyperchlorhydria  Does  Not  Eooclude  the  Presence  of  Ulcer. 
— In  all  doubtful  cases  gastric  analysis  and  examination /or  occult  blood  and 
pus  in  the  stomach  contents  and  for  blood  in  the  stool  should  be  carried  out. 

In  all  cases  we  must  think  of  the  possibility  of  development  of  car- 
cinoma on  the  base  of  a  chronic  ulcer,  but  in  such  event  a  recent  exacerba- 
tion of  symptoms  which  were  previously  less  marked,  loss  of  weight,  weak- 
ness, and  increasing  anemia  are  apt  to  occur.  Cachexia  and  appreciation 
of  tumor  on  palpation  occur  later  and  frequently  when  too  late  for  radical 
operation. 

Urine. — ^The  quantity  is  reduced  when  there  is  much  vomiting  and 
food  is  diminished.     There  are  no  characteristic  changes. 

Complications. — Perforation  and  general  peritonitis;  circumscribed 
peritonitis;  sacculated  abscess;  adhesions  with  other  viscera,  with  or  with- 
out perforation  of  them;  pyloric  stenosis;  stenosis  of  the  cardia;  perigas- 
tritis with  adhesions;  subphrenic  abscess;  perforation  of  the  diaphragm, 
pleura,  lungs,  pericardium,  or  heart;  hour-glass  contraction  of  the  stom- 
ach; external  fistulous  opening;  anemia  of  severe  type;  mediastinal  emphy- 
sema, and  subcutaneous  emphysema  may  occur. 

Stenosis  of  the  pylorus,  due  to  stricture  or  hypertrophy  from  spasm, 
produces  dilatation  of  the  stomach  and  its  symptoms;  stenosis  of  the 
cardia  causes  dysphagia  and  regurgitation  of  food. 

•  Journal  A.  M.  A.,  Aug.  23,  1913. 


ULCER   OF   THE    STOMACH  287 

Perforation. — This  occurs  in  ulcers  on  the  anterior  stomach  wall,  or 
from  perforation  of  a  circumscribed  abscess,  with  resulting  general  peri- 
tonitis. The  symptoms  are  sudden  pain,  at  times  with  a  tearing  sensa- 
tion, shock,  muscular  rigidity,  distention  of  the  abdomen;  and  tenderness 
on  pressure,  disappearance  of  liver  dulness,  cold  sweat,  rapid  and  feeble 
pulse,  followed  by  a  rise  of  temperature,  singultus;  frequently  vomiting, 
anxious  and  sunken  face  (fades  Hippocratica),  usually  coma,  then  death. 
Leukocytosis,  especially  increase  in  the  polynuclears,  is  present.  Blood  may 
be  vomited  and  appear  in  the  stool.  It  is  interesting  to  observe  that  in 
some  patients,  particularly  when  the  leakage  is  light,  the  shock  may  be 
transient  or  even  slight.  Nausea  and  vomiting  are  of  value  as  symptoms. 
During  the  first  few  hours  the  pulse  may  be  only  moderately  increased 
and  but  little  increase  in  the  temperature  but  the  respirations  become  more 
rapid  due  to  abdominal  muscular  rigidity.  Directly  after  the  perforation 
rigidity  is  most  marked  in  the  upper  abdomen  but  later  becomes  general. 
Tenderness  directly  after  perforation  is  marked  over  the  site  of  perforation 
but  later  becomes  general.  If  perforation  occurs  at  the  pylorus — just  as 
with  duodenal  ulcer — the  peritonitis  may  spread  into  the  right  iliac  fossa 
and  simulate  perforated  appendicitis.  Pelvic  and  rectal  tenderness  assist 
in  determining  the  general  peritonitis.  In  the  later  stages  with  the  general 
peritonitis  we  have  the  symptoms  noted  above. 

In  perforation',  with  circumscribed  abscess  formation,  the  symptoms 
are  less  intense  and  are  localized.  Perforation  of  the  stomach  occurs 
usually  after  a  full  meal,  or  following  coughing,  sneezing,  or  local  mechanic 
violence. 

If  adhesions  form  with  other  organs,  these  may  be  perforated. 

Frequency  of  Perforation. — Brinton  gives  the  frequency  of  perforation 
as  I  in  eight  cases.     Others  place  it  at  6  to  7  per  cent. 

In  women,  Brinton  places  one-half  the  perforations  at  the  age  of  four- 
teen to  thirty,  the  average  being  twenty-seven;  while  in  men  they  are 
distributed  up  to  fifty,  the  average  age  being  forty-two. 

The  chances  of  perforation  of  an  ulcer  on  the  anterior  stomach  wall  are 
5  to  I  in  its  favor,  on  account  of  its  mobility,  which  prevents  adhesion 
formation,  but  ulcers  are  much  less  frequent  in  this  location. 

Subphrenic  abscess  (pyopneumothorax  subphrenicus,  when  gas  is  pres- 
ent) may  occur. 

Etiology. — The  chief  causes  are  as  follows:  Posterior  perforating  ulcer 
of  the  stomach  (the  most  frequent  cause);  traumatism  of  the  liver;  abscess 
of  the  liver;  retro  verted  appendix,  and  perforation  of  a  duodenal  ulcer. 

The  boundaries  of  the  abscess-cavity  are:  above,  the  diaphragm;  below, 
the  stomach  and  liver;  to  the  left,  the  spleen;  to  the  right,  the  suspensory 
ligaments  of  the  liver.  The  liver  is  pushed  down  and  the  diaphragm  up- 
ward. 

Symptoms. — These  are  abrupt  when  due  to  perforation  of  gastric  ulcer 
and  are  as  follows:  severe  pain;  vomiting  of  bilious  or  bloody  material; 
embarrassment  of  respiration;  subsequently  chills,  fever,  tenderness  on 
pressure,  and  emaciation.  Leukocytosis  and  increased  polynuclears 
occur  during  the  suppurative  period. 


288  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Physical  signs  depend  on  the  quantity  of  air  in  the  cavity  and  upon 
the  presence  or  absence  of  a  complicating  pleurisy. 

Physical  Signs  (with  Little  Air  Present). — Dulness  or  flatness  in  the 
lower  part  of  the  thorax,  but  cough  and  expectoration  are  absent;  signs 
of  pressure  in  the  pleural  cavity  are  absent  or  slight,  the  thorax  not  being 
much  dilated,  and  there  being  scarcely  any  obliteration  of  the  intercostal 
spaces;  the  lungs  are  intact  and  distensible,  and  on  deep  inspiration  there 
is  vesicular  breathing. 

Physical  Signs  (with  Much  Air  Present). — The  lower  part  of  the  thorax 
protrudes  and  respiratory  movements  diminish;  the  heart  is  sometimes 
pushed  upward  and  slightly  to  the  right;  the  liver  extends  well  down  into 
the  abdomen,  occasionally  as  far  as  the  umbilicus;  the  liver  dulness  in  the 
back  and  lower  part  of  the  lung  is  replaced  by  a  tympanitic  zone;  on  aus- 
cultation the  respiratory  sounds  are  absent  in  this  zone,  and  there  are  suc- 
cussion  sounds  of  a  metallic  pitch. 

When  pleurisy  complicates  subphrenic  abscess  from  ulcer,  there  are 
the  signs  of  pleurisy.     Senator  gives  the  following  diagnostic  points: 

Violent  pain  in  the  epigastric  and  hypochondriac  region;  pain  in  the 
back  on  sitting  up;  pain  on  belching;  patients  prefer  dorsal  position  when 
abscess  complicates;  while  with  pleurisy  alone,  they  lie  on  the  diseased 
side;  edema  of  the  lower  lateral  and  posterior  thoracic  walls. 

Pfuhl  suggests  a  diagnostic  point  between  subphrenic  abscess  and  pyo- 
pneumothorax. 

With  subphrenic  abscess,  if  an  aspirating  needle  be  inserted  and  a 
manometer  be  attached,  the  pressure  is  greater  on  inspiration  and  less  on 
expiration. 

With  pyopneumothorax  the  pressure  conditions  are  reversed. 

Exploratory  puncture  is  the  accurate  method  of  diagnosis,  pus  and  food 
particles  being  aspirated. 

X-rays. — These  show  signs  of  a  high  diaphragm  on  the  right  side  in 
the  rontgenograph.  Lee  reports  cases  of  subdiaphragmatic  inflammation 
without  abscess,  notably  one  case  of  colon  bacillus  infection. 

Terminations  of  Subphrenic  Abscess. — Perforation  of  the  diaphragm 
and  pleura;  perforation  of  the  lung,  with  expectoration  of  pus;  or  of  the 
pericardium;  or  of  the  left  ventricle;  or  of  the  colon;  rarely  perforation 
into  the  general  peritoneum;  or  perforation  of  the  skin,  with  resulting 
fistula. 

Successful  operations  have  been  performed  for  subdiaphragmatic  ab- 
scess, notably  by  Carl  Beck.^  Tuberculosis  may  occur  in  association  with 
ulcer. 

Some  authors  describe  so-called  atypic  forms  of  ulcer,  taking  the  most 
prominent  symptom  as  a  basis,  such  as:  Gastralgic;  catarrhal  or  vomiting; 
dyspeptic  or  latent;  hemorrhagic;  cachectic  or  perforative. 

Diagnosis. — This  is  easy  in  the  typic  form  characterized  by  hematem- 
esis,  the  epigastric  pain  circumscribed  and  present  during  the  digestive 
process,  the  dorsal  pain,  local  tenderness,  and  vomiting.  This  constitutes 
the  acute  type  of  ulcer. 

Cohnheim  holds  that  real  pain  referred  to  the  stomach  is  usually  due 
1  Medical  Record,  Feb.  5,  1896. 


ULCER   OF   THE    STOMACH  289 

to  an  organic  lesion  somewhere,  and  almost  never  to  a  neurosis.  There 
are  two  methods  of  determining  whether  the  pain  is  of  gastric  origin  or  not, 
and  which  may  assist  us  in  our  diagnosis  of  gastric  ulcer:  First,  gastric 
sedatives  during  the  occurrence  of  the  pain  are  given  on  an  empty  stomach, 
such  as  orthoform  or  anesthesin,  5  grains  (0.3);  or  cocain,  }4  grain;  or 
chloroform-water,  i  to  2  drams  (4.0-8.0).  If  the  pain  is  controlled  directly, 
it  is  gastric  (usually  ulcer).  The  second  method  was  devised  by  Bonnin- 
ger.^  After  washing  out  the  stomach  and  examining  the  washings  for 
blood-cells,  etc.,  he  introduces  through  the  tube  200  c.c.  of  a  decinormal 
solution  of  hydrochloric  acid  (concentrated  HCl,  3.6  c.c;  water,  looo  c.c). 
If  a  gastric  ulcer  is  present,  this  acid  solution  will  probably  cause  immedi- 
ate pain.  If  the  pain  is  due  to  other  causes,  the  test  will  be  negative. 
This  method  is  also  used  to  show  the  progress  and  result  of  treatment. 
1  he  test  with  orthoform  or  anesthesin  may  be  tried. 

In  the  less  severe  and  non-typic  cases  (i.e.,  without  hematemesis)  one 
frequently  finds  hyperchlorhydria,  the  presence  of  occult  blood  in  the 
vomitus  or  stool,  and  pus  on  microscopic  examination,  either  after  the  test- 
meal  or  on  aspirating  the  empty  stomach.  With  cases  belonging  to  the 
acute  type  I  have  never  failed  to  find  occult  blood,  pus,  or  the  combina- 
tion, though  sometimes  several  examinations  may  be  necessary.  The 
Mayos  report  blood  as  found  in  only  about  33  per  cent,  of  their  gastric 
and  duodenal  ulcer  cases.  It  will  be  noted  that  a  large  percentage  of  their 
operative  cases  were  those  in  which  food  remnants  (motor  disturbances) 
were  present.  Cases  with  motor  disturbances  pointing  to  stenosis  or 
spasm  of  the  pylorus  as  the  cause  are,  in  the  majority  of  instances,  due  to 
ulcer  (benign  or  malignant)  at  the  pylorus,  and  the  condition  is  frequently 
chronic.  In  these  cases  one  may  at  times  find  pus  in  the  gastric  contents 
and  occult  blood  more  rarely,  but  the  condition  is  surgical  in  any  event. 
On  the  other  hand,  with  chronic  ulcer  involving  the  body  or  curvatures 
of  the  stomach,  and  not  lying  within  the  pylorus,  microscopic  pus  is  usually 
found  according  to  my  experience.  Occult  blood  is  sometimes  present. 
Pus  or  pus  and  blood  in  the  gastric  contents,  when  not  ingested,  or  when 
I  here  is  no  abscess  of  the  stomach,  show  ulceration.  This  was  demonstrated 
in  Connors'  case  already  referred  to.  It  is  chiefly  in  the  chronic  cases  thai 
acidity  is  reduced.  One  must  then  determine  whether  the  ulcer  is  benign 
or  malignant  by  careful  investigation  into  the  history  and  observations 
as  to  rapid  loss  of  weight,  etc.  As  already  noted  this  diflferentiation  is 
often  impossible  and  such  cases  should  be  treated  as  cancer. 

X-ray  Diagnosis. — The  Rontgen  rays  are  one  of  the  most  valuable 
methods  as  an  aid.  to  diagnosis.  In  acute  ulcer,  with  hemorrhage  and  the 
typic  symptoms,  the  x"-rays  are  unnecessary  for  diagnostic  purpose,  in 
fact,  immediate  resort  to  bed  and  active  treatment  are  indicated.  Sub- 
sequently even  after  apparent  cure,  their  employment  is  a  wise  procedure, 
as  one  can  determine  thereby  whether  or  not  deformity  is  produced  by  the 
healing  process  or  motor  disturbances,  such  as  might  indicate  that  ulti- 
mate excision  of  the  scar  area  would  be  preferable.  For  the  aid  in  diag- 
nosis of  chronic  gastric  ulcer,  the  :r-rays  are  invaluable.  Fluoroscopy  and 
radiography  are  both  employed.  The  writer  feels  that  in  the  former 
'  Amer.  Jour.  Med.  Sci.,  June,  1908. 


29©  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

erroneous  interpretation  on  the  part  of  the  operator  is  a  possibility,  while 
the  radiographs  are  more  accurate.  Under  the  section  .-r-rays  in  Gastro- 
intestinal Diseases  the  radiographic  findings  of  gastric  ulcer  are  fully  de- 
scribed. Among  them  were  the  bismuth  residue  in  the  stomach  six  hours 
after  the  meal,  which  in  connection  with  obliteration  or  deformity  at  the 
pylorus  may  show  a  contracting  ulcer  producing  stenosis.  A  small  erosion 
or  ulcer  near  the  pylorus  may  produce  spasm  of  the  pylorus  and  some 
bismuth  retention.  The  writer  believes  that  with  these  cases  peristaltic 
unrest  and  often  hypersecretion  occur  in  addition  to  hyperacidity.  On 
the  other  hand  he  has  seen  pyloric  spasm  and  increased  peristalsis  occur 
with  high  degrees  of  acidity — the  patient  complaining  of  local  tenderness 
as  with  ulcer.  Correction  of  the  hyperchlorhydria  with  the  use  of  large 
doses  of  belladonna  or  atropin  have  corrected  the  condition.  One  also 
frequently  determines  a  chronic  appendicitis  with  secondary  gastric  symp- 
toms, sometimes  those  of  gastric  ulcer.  The  cc-rays  beyond  spasm  of  the 
cap  or  Pyloric  spasm  with  hyperperistalsis  may  show  nothing.  Associated 
reflex  hyperacidity  may  be  a  factor.  Removal  of  the  appendix  and  treat- 
ment of  the  local  conditions  frequently  cures  the  case.  Appendectomy, 
however,  is  necessary.  On  some  occasions,  however,  the  writer  observes 
that  the  tenderness  etc.,  still  persists  and  cure  does  not  result,  in  which 
event  some  small  superficial  ulcer  or  erosion,  undoubtedly  present,  persist. 
Among  other  radiological  findings  in  gastric  ulcer  are  displacement  of  the 
pylorus  upward  and  to  the  left — "snail  form,"  undershot  appearance  of 
the  stomach,  hour-glass  contraction,  any  distortion  or  displacement  of 
the  stomach  by  adhesions,  distortion  (projection)  on  one  curvature  with 
a  deep  incisura  on  the  opposite  curvature,  a  small  puckered  area  with  dis- 
torted rugae  with  disturbance  in  motility,  the  niche,  or  a  bismuth  patch 
retained  in  the  stomach,  or  an  ulcer  crater  with  bubble  of  air  showing  per- 
forated ulcer  (the  accessory  cavity  described  by  Carman).  Incidentally 
some  of  the  distortions  cannot  be  differentiated  from  those  due  to  gall- 
bladder infection  with  adhesions,  or  malignancy,  except  by  taking  into 
consideration  the  physical  examination  and  clinical  symptoms.  The  bis- 
muth patch  method  is  based  on  the  principle  that  a  bismuth  deposit  occurs 
on  the  ulcerated  surface  and  remains  there  for  a  period,  even  though  the 
rest  of  the  organ  is  clear.  Adler^  determines  the  motility  of  the  stomach. 
He  administers  i^  drams  of  bismuth  subcarbonate  in  half  a  glass  of  water 
on  an  empty  stomach.  The  picture  is  taken  four  to  six  hours  later.  This 
allows  ample  time  for  all  bismuth  to  disappear  from  the  stomach  or  duo- 
denum, so  that  there  alone  remains  that  which  is  deposited  in  the  crater 
of  an  ulcer.  After  this  first  a;-ray  examination,  i  ounce  of  bismuth  sub- 
carbonate  is  given  in  a  glass  of  water,  and  a  second  picture  taken  immedi- 
ately. The  bismuth  spreads  rapidly  over  the  gastric  mucous  membrane. 
This  last  can  be  facilitated  by  having  the  patient  turn  from  side  to  side 
several  times.  By  this  second  examination  the  shadow  of  the  entire 
stomach  is  shown,  so  that  the  shadow  obtained  on  the  first  plate  can  be 
localized  with  reference  to  its  relation  to  the  stomach. 

*  Jour.  Amer.  Med.  Assoc,  Nov.  12,  1910. 


ULCER   OF   THE    STOMACH 


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294  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Invaluable  as  the  a;-rays  are  as  an  aid  to  diagnosis,  the  latter  should 
not  he  made  from  them  alone,  but  the  clinical  symptoms  should  be  consid- 
ered as  otherwise  incorrect  interpretation  will  occur. 

Other  conditions  have  been  mistaken  for  gastric  ulcer.  With  Gastric 
crises  oj  locomotor  ataxia,  we  have  absence  of  patellar  reflexes.  Romberg 
symptom  and  the  Argyll-Robertson  pupil  are  diagnostic.  The  Wasser- 
mann  test  should  be  made  in  doubtful  cases  and  the  tc-rays  employed. 

Duodenal  Ulcer. — This  is  at  times  impossible  to  differentiate,  if  the 
ulcer  extends  through  the  pylorus.  There  is  a  history  of  long  duration 
(chronicity),  periodicity  and  the  symptoms  occur  in  attacks.  Pus  absent 
in  gastric  contents.  It  occurs  most  frequently  in  males;  is  often  latent; 
melena  is  frequent;  pain  and  tenderness  are  often  a  little  more  to  the  right 
than  in  gastric  ulcer;  no  local  dorsal  pain  spot;  hematemesis  not  as  fre- 
quent; pain  after  the  ingestion  of  food  is  later  than  in  gastric  ulcer.  Hun- 
ger pain,  occurring  two  hours  or  more  after  the  meal,  is  relieved  by  food. 
Occult  blood  is  most  frequent  in  the  stool  and  there  is  symptomatic  (often 
not  true)  hyperacidity.  (Under  Differential  Diagnosis  of  Duodenal  Ulcer 
further  data  are  given.  0 

Spider  Gall-bladder  Adhesions. — Robert  T.  Morris  has  demonstrated 
that  gastric  hemorrhage  occurs  at  times  with  this  condition.  The  stom- 
ach is  dilated,  and  the  diagnosis  has  been  made  of  stenosis  of  the  pylorus 
with  ulcer. 

There  is  a  previous  history  of  gall-bladder  disease  in  these  cases. 
The  possibility  of  this  condition  must  be  considered. 

Cirrhosis  of  the  Liver. — Severe  gastric  hemorrhage  may  occur,  but 
examination  of  the  liver,  the  history,  and  other  symptoms  will  differentiate. 

Chronic  Tuberculous  Diaphragmatic  Pleurisy  with  Symptoms  Re- 
sembling Gastric  Ulcer. — Male^  reports  a  series  of  cases  giving  the  symp- 
toms-complex— pain,  vomiting  and  gas  of  gastric  ulcer.  Adhesions  be- 
tween the  diaphragm  and  pleura  and  pain  referred  along  the  course  of 
the  intercostal  nerves  to  their  termination  over  the  abdomen  were  re- 
sponsible. Radiographs  demonstrated  retraction  of  the  diaphragm, 
calcified  lymph-nodes  and  other  evidences  of  pulmonary  disease.  Some 
of  these  patients  had  no  cough,  no  temperature  and  no  expectoration. 
This  possibility  must  be  remembered. 

Location  of  the  Ulcer. — Occasionally  one  can  make  a  probable  diag- 
nosis as  to  the  position  of  the  ulcer;  if  relief  is  afforded  when  standing, 
the  ulcer  is  probably  on  the  lesser  curvature;  if  pain  is  intense  on  standing, 
it  is  on  the  greater  curvature;  if  less  severe  pain  when  lying  on  left  side, 
the  ulcer  is  probably  at  the  pylorus,  etc.  The  position  which  affords 
most  comfort  to  the  patient  is  the  one  which  permits  the  ulcer  to  remain 
above  the  gastric  contents. 

Einhorn^  has  described  two  methods  for  recognizing  and  localizing 
gastric  ulcers:  the  so-called  "thread  impregnation  test,"  in  which  the 
patient  swallows  the  duodenal  bucket  with  thread  attachment,  which  is 
removed  ten  to  twelve  hours  later.     Blood  discoloration  on  the  string 

^  "Roentgen  Diagnosis  of  Gastric  Ulcer,"  Mayo  Clinic,  vol.  vi.  1914. 
*  Journal  A.  M.  A.,  Feb.  28,  1914. 

'  Med.  Rec,  April  3,  1909;  Internat.  Jour,  of  Surg.,  November,  1909;  and  Med. 
Rec.,  March  18,  1911. 


ULCER   OF  THE   STOMACH  295 

shows  the  presence  of  ulcer,  and  the  distance  of  this  spot  from  the  teeth, 
its  location.  Sufficient  blood  to  discolor  the  thread  would  generally 
respond  to  the  test  for  occult  blood  in  the  gastric  contents.  The  method 
presupposes  that  the  string  will  pass  over  the  ulcerated  surface  which  it 
may  not  do  at  all,  or  may  abrade  the  surface  through  irritation  at  the 
pylorus  or  at  the  time  of  removal.  His  second  method,  by  the  "gastric 
stamper,"  consists  in  the  introduction  of  a  collapsed  balloon  into  the 
stomach,  which  is  then  distended,  and  secures  an  impression  of  blood  from 
the  ulcer.  It  is  then  deflated  and  removed.  Both  methods  are  uncertain, 
and  pressure  from  inflation,  I  believe,  dangerous.  The  use  of  the  gastro- 
scope  to  locate  the  ulcer  is  a  risky  procedure.  The  :r-rays  are  of  great 
value  in  locating  the  ulcer  in  most  cases,  but  not  invariably  as  previously 
noted,  thus  when  there  is  a  superficial  ulcer  or  erosion  without  deformity. 
Hyperperistalsis,  however,  would  be  suggestive.  The  presence  of  blood 
or  occult  blood  in  the  gastric  contents,  vomitus,  or  stool,  the  determina- 
tion of  pus  in  the  gastric  contents  together  with  the  methods  of  diagnosis 
previously  described,  are  often  sufficient  for  diagnosis. 

Course. — Gastric  ulcer  occasionally  runs  a  rapid  course,  with  death 
from  perforation  or  hemorrhage.  Stowell^  states  that  18  per  cent,  last 
a  year  or  less;  46.5  per  cent.,  from  one  to  six  years.  A  case  of  thirty 
years'  duration  has  been  reported.  There  are  often  intermissions  of 
improvement  and  exacerbations;  or  the  patient  may  become  a  chronic 
invalid.     The  subsequent  development  of  cancer  is  the  worst  danger. 

Prognosis. — Excepting  the  fulminating  cases,  the  more  recent  the 
ulcer,  the  more  favorable  the  prognosis  as  to  cure. 

The  mortality  has  been  estimated  at  from  8  to  10  per  cent.;  some 
place  it  up  to  20  per  cent.  In  private  practice  Musser  believes  the 
mortality  of  ulcers  treated  medically  to  be  3.1  per  cent.,  while  in  hospital 
cases  it  was  12.4  per  cent.  The  position  of  the  ulcer  modifies  the  prog- 
nosis: if  on  the  anterior  wall,  perforation  is  more  apt  to  occur;  if  the 
pylorus  is  involved,  stenosis  and  dilatation  of  the  stomach  result;  if 
hypersecretion  be  associated,  the  results  are  less  favorable.  Stowell's 
statistics  are  as  follows: 

Death  from  hemorrhage,  3  to  4  per  cent.;  from  exhaustion,  5  per 
cent.;  from  fatal  perforation,  6.5  to  13  per  cent.  Pulmonary  tuberculosis 
was  the  terminal  event  in  20  per  cent.  (Debove  and  Remond)  out  of  loo 
cases  investigated. 

Greenough  and  Joslin,  in  the  Massachusetts  General  Hospital,  found 
that  while  82  per  cent,  cases  of  ulcer  were  discharged  as  cured  or  re- 
lieved, only  40  per  cent,  remained  well.  Leube's  marvelous  statistics 
of  medical  cure,  90  per  cent.,  are  based  on  a  very  brief  period  and  are 
of  no  value.     Three  years  should  elapse. 

The  statistics  of  500  cases  at  the  London  hospital  show  that  50  per 
cent,  were  uncured  by  medical  means,  and  of  those  discharged  as  cured, 
one-half  relapsed.  Parker  Syms^  believes  that  the  mortality  of  cases 
treated  medically  will  reach  beyond  50  per  cent.,  since  though  the  majority 
do  not  die  from  the  immediate  effects  of  the  ulcer,  yet  the  anemia  and 

1  Med.  Rec.  July  8,  1905. 

*  Some  Surgical  Aspects  of  Gastric  Ulcer,  N.  Y.  Med.  Jour.,  July  16,  1910. 


296  DISEASES    or    THE    STOMACH    AND    INTESTINES 

Starvation  so  reduce  their  vital  forces  that  they  become  a  ready  prey  to 
intercurrent  diseases.  Chronic  ulcer  is  responsible  for  about  70  per  cent, 
of  cancer  of  the  stomach.  Eliminating  the  dangers  of  death  from  hemor- 
rhage or  perforation,  the  author  believes  the  acute  type  of  idcer  the  most 
favorable  for  cure,  while  the  chronic  cases,  as  a  rule,  belong  to  the  province 
of  the  surgeon.  Lockwood^  holds  that  the  mortality  for  gastro-enteros- 
tomy  for  ulcer  is  2  to  3  per  cent,  in  the  hands  of  a  skilled  surgeon,  and  6  to 
8  per  cent,  by  the  average  surgeon;  while  in  more  complicated  operations 
the  mortality  was  10  to  15  per  cent.  The  writer  believes  that  about  80 
to  90  per  cent,  of  chronic  cases  are  cured  by  surgical  intervention. 

Treatment. — For  Hemorrhage  (Hematemesis). — Absolute  rest  in  the 
dorsal  position;  immediate  injection  of  morphin  sulphate,  J^  to  K  grain 
(0.008-0.016),  and  the  application  of  a  light  ice-bag  over  the  stomach, 
if  necessary  suspended  from  a  barrel  hoop  to  avoid  weight.  In  emer- 
gency I  have  tied  bits  of  ice  in  a  sheet  of  rubber  tissue  or  in  dress  shields. 

One  to  two  teaspoonfuls  of  a  5  to  10  per  cent,  solution  of  gelatin 
(cold),  depending  on  the  severity  of  the  case,  should  be  given  by  mouth 
every  half-hour  for  ten  to  twelve  hours,  even  if  vomiting.  This  is  an 
excellent  hemostatic,  and  also  takes  up  the  free  acid. 

The  frequent  administration  of  small  quantities  is  preferable  to  larger 
amounts  given  every  two  or  three  hours. 

Gelatin,  3  ounces  (100  c.c.)  of  a  2  per  cent,  solution  by  hypodermic 
with  a  large  syringe,  given  between  the  lowest  rib  and  crest  of  the  ilium, 
is  of  value. 

Ernutin  (Burroughs,  Wellcome  &  Co.),  5  to  10  minims  (0.33-0.66), 
by  hypodermic,  or, 

I^.  Ext.  ergot gr-  xv  (i.o); 

Glycerini     "I  ...,■,      s 

Aq.   destil.) ^^  ^J^*°)- 

by  a  large  syringe  subcutaneously  have  proved  useful  adjuncts;  or  fluid- 
extract  of  ergot  or  hydrastis,  i  to  2  drams  (4.0-8.0),  in  2  ounces  of  water 
by  rectum. 

Chlorid  or  iron  and  acetate  of  lead  are  objectionable.  Emetine 
hydrochloride  gr.  J4  by  hypodermic  has  been  recommended.  Tannic 
acid  gr.  v  t.i.d.  in  soft  capsule  has  been  employed. 

Tremoliere  has  recently  advocated  a  solution  as  a  local  styptic  con- 
sisting of  a  5  per  cent,  gelatin  solution  containing  2  per  cent,  chlorid  of 
calcium.  In  a  severe  case  I  should  not  hesitate  to  give  at  once  by  mouth 
I  to  2  ounces  of  a  10  per  cent,  gelatin  solution  containing  5  to  10  grains 
(0.3-0.6)  of  chlorid  or,  preferably,  lactate  of  calcium. 

The  drug  is  dissolved  in  a  little  water  and  added  to  the  gelatin  solution 
while  still  warm,  and  then  rapidly  cooled  off  on  ice. 

The  plain  gelatin  solution  should  be  administered  tn  every  case. 

Lactate,  or  chlorid  of  calcium,  10  to  15  grains  (0.66-1.0),  in  4  ounces 
(125  c.c.)  of  warm  water  can  be  given  by  enema  as  an  adjuvant. 

Lactate  of  strontium,  or  lactate  of  magnesium,  15  to  30  grains  (i.o- 
2.0),  in  2  to  3  ounces  (125  to  200  c.c.)  of  sterile  water,  are  recommended 

^  The  Prognosis  and  End  Results  of  Treatment  of  Gastric  Ulcer,  Jour.  Amer. 
Med  Assoc,  April,  191 1. 


ULCER   OF    THE    ST0MAC:H  297 

by  hypodermoclysis,  by  Maas,  to  increase  the  coagulability  of  the  blood, 
and  would  be  valuable  in  gastric  hemorrhage.  Calcium  chlorid  should 
never  be  so  given,  as  it  causes  local  coagulation  necrosis,  and  the  lactate 
of  calcium  never  stronger  than  i :  20  by  hypodermic,  and  even  so  there  is 
danger. 

Adrenalin  chlorid  (1:1000),  5  to  15  minims  (0.66-1.0),  has  been 
recommended  by  hypodermic  for  internal  hemorrhage,  but  the  pulse 
tension  is  markedly  increased  thereby,  and  I  have  seen  secondary  hemor- 
rhage result.  Five  drops  may  be  given  by  the  mouth  in  2  drams  (8.0) 
of  water  for  the  local  styptic  effect  if  other  remedies  are  insufl5cient. 

Bismuth  subnitrate,  \2  dram  (2.0)  in  i  ounce  of  water,  is  at  times  of 
service. 

Ewald  recommends  cautious  lavage  with  ice-water  after  cocainiz- 
ing the  pharynx  (2  per  cent,  solution  of  cocain  is  sufficiently  strong 
by  spray),  in  cases  in  which  death  seemed  imminent  from  continuous 
hemorrhage.  I  have  never  found  the  procedure  necessary,  though 
I  have  treated  severe  cases.  If  it  is  employed,  the  addition  of  4  ounces 
(125  c.c.)  of  a  5  per  cent,  gelatin  solution,  15  grains  (i.o)  lactate  of  cal- 
cium, and  10  minims  (0.66)  adrenalin  to  the  water  for  lavage  would  be  of 
advantage. 

J.  Kaufmann^  recommends  gentle  gastric  lavage,  the  quantity  of 
water  at  a  washing  about  300  c.c.  The  patient  should  lie  down  during 
the  lavage,  and  the  tube  should  be  inserted  just  far  enough  to  secure 
siphonage.  If  the  hemorrhage  has  ceased,  he  does  not  wash  the  stomach, 
but  only  if  the  bleeding  is  continuing.  He  believes  there  is  no  danger 
of  perforation  unless  the  operator  should  overdistend  the  stomach  by 
large  quantities  of  water.  He  advocates  the  serum  treatment  of  hemor- 
rhage, and  large  doses  of  crystalline  bismuth  subnitrate  to  aid  in  the 
coagulation  of  the  blood.  Kaufmann  further  argues  that  the  removal  of 
the  masses  of  clotted  and  disintegrated  blood,  which  may  cause  gas 
formation  and  gastric  distention,  would  lessen  the  chance  of  subsequent 
recurrence  of  the  hemorrhage. 

Wiel  advises  lavage  with  hot  water  at  42°C.,  but  I  doubt  its  ad- 
visability. W.  L.  Rodman  advocates  lavage  with  hot  water  at  120° 
to  i30°F.  When  all  methods  fail,  and  the  hemorrhage  continues  or  soon 
recurs,  opening  the  stomach  and  direct  suture  of  the  bleeding  ulcer  has  been 
advised.  The  author  holds  that  a  temperature  of  130"  is  too  high;  120°  is 
the  maximum. 

The  administration  of  sterile  horse-serum,  as  described  by  Hort 
shortly,  might  be  of  value.  The  hypodermic  use  of  normal  human  blood- 
serum  in  cases  of  hemophilia  neonatorum  has  been  successfully  employed 
by  Welch.^  It  may  be  used  for  severe  hematemesis  in  doses  of  20  c.c  or 
more.  Serum  sickness,  which  might  occur  from  the  use  of  animal  serum 
by  this  method,  is  thus  avoided. 

For  Thirst. — The  cold  gelatin  given  for  hemorrhage  helps  relieve 
thirst.  A  small  piece  of  gauze  dipped  in  cold  water  and  held  in  the 
mouth,  frequent  washing  of  the  latter;  an  occasional  pellet  of  ice  and 

'  Amer.  Jour.  Med.  Sci.,  June,  1910. 
2  Ibid. 


298  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

enemata  of  normal  saline  solution  at  io5°F.,  4  to  5  ounces  (125  to  200  c.c), 
if  no  relief  by  other  methods,  and  given  every  three  hours. 

Proctoclysis,  the  administration  of  saline  solution  per  rectum  by 
the  drop  method,  is  also  useful.  Hypodermoclysis  is  of  value  employing 
5  vi-5  viii. 

Collapse. — Caution  must  be  employed  not  to  overstimulate  the 
heart,  lest  the  coagulum  be  forced  out  and  hemorrhage  recur. 

Only  collapse  that  is  fairly  marked — a  pulse  120  or  over — should 
be  treated,  as  depression  of  the  pulse  favors  clotting.  Among  the  valuable 
methods  are: 

External  application  of  heat  to  the  limbs  by  hot- water  bags;  rectal 
injections  of  i  pint  (500  c.c.)  to  i  quart  (liter)  of  hot  normal  salt  solution 
at  115°  to  i2o°F.  every  two  to  three  hours;  proctoclysis  may  also  be 
employed. 

Hypodermoclysis  with  normal  saHne  solution,  6  ounces  to  i  pint 
(375  to  500  c.c),  given  at  io5°F.,  through  a  large  needle  attached  to  a 
fountain  syringe,  preferably  between  the  iliac  crest  and  twelfth  rib, 
is  valuable,  and  does  not  stimulate  too  rapidly. 

In  emergency  I  saved  one  patient  by  employing  an  ordinary  hypo- 
dermic needle  and  elevating  the  fountain  syringe  6  to  8  feet  to  obtain 
forcible  flow.  In  this  event  a  higher  temperature  (ii8°F.)  should  be 
employed,  as  the  fluid  cools  in  passing  through  the  small  needle. 

In  one  case  apparently  in  extremis,  having  no  time  to  perform  infusion 
and  also  no  assistance  procurable,  being  in  the  mountains,  I  needled 
a  large  superficial  vein  with  a  hypodermic  needle^  and  infused  by  this 
method,  elevating  the  fountain  syringe  about  6  feet.  The  patient  re- 
covered. Infusion  with  i  liter  of  normal  saline  solution  at  1 2o°F.  in  severe 
cases  is  indicated.  Direct  infusion  of  blood  from  donor  to  patient  is  often 
impractical,  and  the  simple  method  is  the  best.  Direct  infusion  from 
donor  to  patient  may  be  employed  in  some  cases.  A  careful  selection  of 
the  donor  must  be  made. 

Strychnin,  3^0  to  }4q  grain  (0.00108-0.002 1),  every  three  or  four 
hours  by  hypodermic,  or  pulverized  camphor,  5  grains  (0.3),  in  sterile 
almond  oil,  20  minims  (1.184  c.c).  Large  doses  of  camphor  (20  grains) 
may  be  necessary. 

A  single  dose  by  hypodermic,  and  repeated  in  three  or  four  hours,  is 
often  required.  Bandaging  the  extremities  and  elevation  of  the  foot  of 
the  bed  are  of  service. 

Whiskey  or  brandy,  i  to  2  ounces  (30.0-60.0),  may  be  added  to  the 
enema. 

Author's  Method. — Chief  dependence  should  be  placed  on  morphin, 
the  ice-bag,  gelatin,  and  lactate  of  calcium  and  bismuth  subnitrate 
internally.  Ernutin  is  useful  and  the  serums  may  be  employed  if  nec- 
essary, particularly  human  serum  by  hypodermic. 

The  rational  methods  for  the  cure  of  acute  or  chronic  gastric  ulcer 
differ  widely,  the  chief  exponents  being  Leube-Ziemssen  and  Lenhartz. 

General  Principles. — There  are  certain  general  principles  to  which 
I  must  first  refer. 

*  Manual  on  Enteroclysis,  Hypodermoclysis,  and  Infusion  (Kemp). 


ULCER   OF   THE    STOMACH  299 

Absolute  rest  in  bed  for  a  period  of  two  to  four  weeks,  even  though 
the  hemorrhage  may  not  have  taken  place  recently,  gives  the  best  results. 
The  longest  period  is  preferable. 

Cruveilhier  first  recommended  milk  in  gastric  ulcer  as  an  ideal  food. 
Pure  milk  coagulates  rapidly  with  some  patients  and  does  not  agree. 
Boiled  milk  does  not  form  large  curds  and  leaves  the  stomach  more 
rapidly.     Lime-water  and  milk  of  magnesia  lessen  milk  coagulability. 

Lenhartz  believes  that  the  general  nutrition  should  be  improved 
as  rapidly  as  possible  to  hasten  the  healing  of  the  ulcer,  and  that  sufficient 
milk  to  secure  this  result  requires  so  large  a  quantity  that  it  would  over- 
distend  the  stomach.  Though  given  in  divided  doses,  he  states  that 
2  to  3  quarts  per  diem  are  excessive,  and  limits  the  total  quantity  of 
milk  to  I  liter,  adding  other  materials  to  increase  the  calorie  value. 

Riegel  demonstrated  the  capacity  of  egg-albumen  to  bind  free  hydro- 
chloric acid,  and  also  the  use  of  sugar  solutions  to  lessen  acid  secretion, 
such  as  pure  dextrose  or  even  ordinary  dextrose.  These  possess  high 
calorie  value. 

Soluble  dry  peptonoids,  i  ounce  (30.0),  have  a  calorie  value  of 
120.4.  They  dissolve  in  milk  or  water.  Milk  powder,  100  grams; 
Gartner's  fat  milk;  casein  nutrose,  30  to  60  grams  and  somatose,  4  to  6 
drams  (16.0-24.0)  and  tropon  are  at  times  of  service  as  adjuncts. 

Among  other  foods  are  meat  jelly,  prepared  by  boiling  chicken  or 
beef  with  calves'  feet  (Fleming);  Leube-Rosenthal's  meat  solution;  flour 
soup  boiled  with  milk,  and  barley-water  or  rice-water  to  dilute  the  milk. 

Protection  of  the  gastric  mucosa  and  lessening  hyperchlorhydria 
by  the  use  of  olive  oil — H  to  i  ounce  (16.0-32.0) — t.i.d.  before  meals, 
is  of  service.  Glycerin  in  5i  doses  also  useful  and  the  mineral  oils  par- 
ticularly as  a  carrier  for  bismuth  have  been  suggested. 

Kaufmann^  has  demonstrated  that  the  normal  gastric  mucus  exercises 
a  protective  influence  and  is  absent  in  ulcer,  and  that  silver  nitrate  both  aids 
the  healing  of  ulcer  and  stimulates  mucous  secretion.  Tiirck  substantiates 
this  by  showing  the  increase  of  mycogen  cells  during  the  process  of  healing. 

Large  doses  of  bismuth  act  as  a  protective  layer  to  the  ulcer  and 
prevent  irritation. 

Neutralization  of  the  free  hydrochloric  acid  is  important.  Among 
the  most  valuable  alkalis  are  magnesia  usta,  milk  of  magnesia  (Phillips), 
and  soda  bicarbonate.  Magnesia  preparations  are  also  of  use  for  the 
constipation.    If  their  action  becomes  excessive,  bismuth  can  be  combined. 

At  times  I  employ  soda  bicarbonate  in  combination  with  magnesia. 
Bicarbonate  of  soda  alone  is  apt  to  produce  too  much  carbonic  acid 
gas  and  distend  the  stomach. 

In  cases  without  dilatation,  Carlsbad  water  or  their  salts  are  of 
service,  as  they  lessen  gastric  secretion  and  empty  the  bowels.  They 
form  a  permanent  feature  in  Leube's  cure. 

Belladonna  is  valuable  to  lessen  acidity,  to  relieve  pain  and  spasm 
therefrom  and  also  if  there  is  hypersecretion,  }4  grain  (0.022)  of  the 
extract  or  10  minims  (0.6)  of  the  tincture  three  times  a  day.  Atropin 
gr.  Hoo~Hq  t.i.d.  may  be  substituted. 

^  Amer.  Jour.  Med.  Sci.,  February,  1908. 


300  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Iron  and  arsenic  are  imperative  to  improve  the  condition  of  the 
blood.  Alcoholic  drinks,  coffee  and  tobacco,  heavy  salads,  hot  breads, 
acids,  pastry,  etc.,  should  be  excluded  during  the  course  of  treatment. 

If  nutritive  enemata  are  given  for  twenty -four  hours  following  Leube's 
method,  plain  milk  should  never  be  employed,  but  should  always  be 
peptonized.  This  feature  is  often  overlooked.  An  enema  of  saline 
solution  should  be  administered  an  hour  or  more  before  the  nutritive 
enema,  in  order  to  cleanse  the  bowel.  This  cleansing  enema  may  be 
required  twice  daily  to  relieve  irritation.  The  following  is  of  service: 
Peptonized  milk,  4  ounces  (125  c.c);  raw  egg,  or  whites  of  2  eggs  beaten 
up,  with  salt,  15  grains  (i.oo);  water,  q.  s.  8  ounces  (250  c.c).  An  iso- 
tonic solution  of  dextrose  is  less  irritating  than  glucose,  and  has  con- 
siderable calorie  value.  One  can  add  10  per  cent,  dextrose  or  25  c.c.  to 
each  8-ounce  enema.  A  10  to  15  per  cent,  solution  of  peptone  may  be 
substituted  or  boiled  starch  may  be  added. 

Ewald  advises  2  tablespoons  flour  boiled  with  150  c.c.  water  or  milk 
to  which  add  2  eggs  (raw)  and  50  to  100  c.c.  of  a  15  to  20  solution  of 
glucose  with  a  knife  point  of  salt. 

Boas  employs  250  c.c.  milk  (which  the  author  states  should  be  pep- 
tonized), yolks  of  2  eggs  (raw),  i  tablespoon  Kraftmehl,  i  tablespoon 
red  wine,  a  penknife  point  of  salt  and  5  drops  tinct.  opii.  If  irritation  is 
marked  an  occasional  small  dose  of  opium  in  the  enema  may  be  required. 
It  is  not  advisable  in  every  enema.  It  may  be  necessary  to  use  a  smaller 
enema,  only  4  ounces  (125  c.c). 

Somatose,  2  drams  (8.0),  or  dry  peptonoids,  i  dram  (4.0),  or  liquid 
peptonoids,  1  ounce  (32.0)  may  be  added.  Four  nutritive  enemata  should 
be  given  during  the  day  of  sixteen  hours. 

Metzger  has  shown  that  wine  in  the  enema  increases  gastric  secretion. 

Having  enunciated  the  general  principles  of  treatment,  I  will  describe 
the  chief  methods  employed  and  the  procedures  with  which  I  have  been 
most  successful  in  my  own  experience. 

Riegel  confines  himself  exclusively  to  rectal  feeding  for  six  Or  eight 
days  at  the  commencement  of  treatment  following  hematemesis,  giving 
only  a  few  pieces  of  ice  by  mouth,  and  then  follows  with  a  mild,  non- 
irritating  diet  and  the  use  of  Carlsbad  water  or  salts;  while  others  confine 
the  feeding  to  the  rectum  for  two  or  three  weeks. 

Good  results  have  been  reported,  but,  as  the  patient  is  suffering 
from  subnutrition,  these  methods  can  be  improved  upon. 

Leube-Ziemssen  Rest  Cure. — This  is  substantially  as  follows:  The 
patient  is  kept  in  bed  for  two  or  three  weeks,  not  being  allowed  to  rise 
for  any  purpose,  either  for  defecation  or  urination;  rectal  feeding  for 
three  days  if  hematemesis  has  just  occurred;  hot  poultices  (flaxseed)  over 
the  stomach  by  day  and  warm  Priessnitz  compresses  at  night.  Then 
after  the  first  three  days  the  subsequent  diet  for  ten  days  should  consist 
chiefly  of  milk,  boiled  milk,  or  milk  with  barley-water,  strained  barley, 
oatmeal-  or  rice-water,  tea,  and  a  little  bouillon  or  meat  extract.  Un- 
sweetened biscuits  may  be  added.  On  the  fourth  day,  for  example, 
the  patient  receives  2^  pints  of  milk,  6  ounces  of  rusks  (softened),  and 
some  meat  extract.     For  the  next  ten  days  (second  period)  boiled  calves' 


ULCER  OF   THE  STOMACH  3OI 

brain,  boiled  thymus,  rice,  and  sago  in  milk,  gruels  and  mushes,  raw  and 
soft-boiled  eggs.  This  is  followed  by  a  little  scraped  rare  or  raw  beef. 
Scraped  raw  ham  and  mashed  potato  for  a  week  or  so  are  added,  and, 
finally,  broiled  chicken,  venison,  partridge,  macaroni,  white  bread,  roast 
beef,  pike,  and  shad,  etc. ;  coarse  bread,  skin,  tendons,  fruits,  alcohol,  and 
acids  should  be  avoided. 

Carlsbad  water,  a  glass,  or  i  to  2  drams  (4.0-8.0)  Carlsbad  salts  in 
8  ounces  (250  c.c.)  of  water  should  be  taken  half  an  hour  before  break- 
fast.    This  can  be  begun  after  the  first  week  or  ten  days. 

Ewald^  uses  nutrient  enemas  for  three  days  after  a  hemorrhage,  and 
then  gives  milk,  butter,  and  eggs,  and  gradually  increases  the  diet.  He 
adds  a  labferment  to  the  milk  alone,  or  mixed  with  flour  soup;  later  sayo 
and  tapioca.  At  the  third  week  raw  scraped  ham  and  breast  of  fowl  with 
rolls  or  zwieback  softened  in  cocoa.  He  objects  to  Lenhartz's  method,  but 
practically  employs  a  mixed  method  with  not  as  satisfactory  results. 

Einhorn^  employs  nutritive  enemata  for  a  day  or  so  after  hema- 
temesis,  and  then  milk  as  the  basis  of  his  diet  for  the  first  two  weeks; 
for  the  first  week  giving  5  ounces  (150  c.c.)  every  hour,  adding  barley- 
water  and  bouillon;  and  gradually  increasing  the  quantities  of  milk, 
but  giving  it  at  longer  periods,  adding  eggs,  crackers,  etc.;  at  the  end 
of  ten  days  gradually  increasing  the  diet.  Recently  he  employs  raw 
eggs  and  milk  from  the  first  day. 

Duodenal  Feeding. — Einhorn  now  advocates  duodenal  feeding  in  order 
to  rest  the  stomach,  the  duodenal  tube  employed  being  the  same  as  that 
described  under  Diagnosis  of  Pancreatic  Diseases  "Direct  Method  of 
Securing  Pancreatic  Secretion."  It  is  now  advised  to  swallow  the  per- 
forated capsule  and  tube  on  retiring  at  night,  attaching  the  outer  end  of 
the  tube  to  the  ear  by  a  string. 

Einhorn  recommends  feeding  from  7  a.  m.  to  9  p.  m.  every  two  hours. 
He  employs  as  a  formula,  i  glass  of  milk,  i  raw  egg  beaten  in  and  a 
tablespoon  of  sugar  of  milk.  At  the  start  100  c.c.  of  this  mixture  is 
injected  through  the  tube  by  a  syringe  and  this  is  gradually  increased  to 
280  to  300  c.c,  until  about  2800  calories  are  given  daily.  The  mixture 
should  be  gradually  heated  and  then  strained  and  should  be  given  at  the 
body  temperature  entering  the  duodenum  slowly. 

This  method  the  writer  believes  is  not  to  be  advised  since  the  soft 
rubber  tube  is  irritating  to  the  ulcer,  tends  to  irritate  the  pylorus  by  its 
continuous  presence  during  a  period  of  ten  to  twelve  days,  irritates  the 
pharynx  and  by  its  presence  in  the  stomach  tends  to  increase  secretion 
and  motility.  Flatulence  and  distress  are  often  produced.  The  end- 
results^  secured  do  not  justify  the  method. 

Lenhartz's  Method. — ^Lenhartz*  believes  that  many  cases  of  gastric 
ulcer  do  not  definitely  improve,  or  but  very  slowly,  under  the  method  of 
entrenched  milk  feeding;  that  the  high  acidity  is  not  measurably  lessened; 

^  Centr.  f.  d.  ges.  Therap.,  Sept.,  1906;  also  Deutsch.  med.  Woch.,  1908,  xxiv,  361. 

^  N.  Y.  Med.  Jour.,  Nov.  20,  1909. 

3  The  writer  has  had  no  success  with  this  method,  but  only  disturbance  of  the 
patient,  while  marked  weight  increase,  etc.,  results  from  Lenhartz's  method. 

*  International  Congress  at  Wiesbaden,  1901;  Therap.  Gaz.,  Nov.  16,  1906;  Mitt. 
a.  d.  Hamb.  Staatsk.,  1906,  vi,  345. 


302 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


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S  and  that  if  patients  are  in  a  poor 
«  physical  condition  consequent 
«  upon  one  or  more  hemorrhages, 
^  often,  indeed,  in  collapse,  the 
^  "starvation  treatment" — the  ice 
c  and  nutrient  enemata  and  insuffi- 
4,  cient  milk  feeding  following — not 
only  maintain  the  patient  in  his 
anemic  state,  but  may  even  drag 
him  into  serious  inanition,  and 
such  an  undermined  constitution 
hardly  favors  the  speedy  healing 
of  an  ulcer.  Frequent  nutrient 
3  enemata  excite  the  gastro-intesti- 
'^  nal  tract  into  peristaltic  activity 
"5  and  may  thus  induce  renewed 
■2  bleeding;  besides,  very  little  nu- 
^  triment  is,  after  all,  obtainable. 
>  Should    more   milk   be   given 

Z  by  mouth,  merely  enough  to  pre- 
■^      serve  the   body   weight — 3   liters 

0  for  an  adult — it  would  overfill  the 
T-  stomach  and  stretch  its  walls,  thus 
^  preventmg  a  contraction  of  the 
^      ulcer  and  again  offering  the  dan- 

1  ger  of  renewed  bleeding.  He  ad- 
g,  vises  another  dietary  treatment, 
«  one  that  will  especially  combat 
%  the  hyperchlorhydria  and  rein- 
V      force    the  enfeebled  and  anemic 

M  ... 

^  State  of  the  patient. 

•%  The  concentrated  egg-albumen 

•%  diet  was  tried.     In  case  after  case 

•^  the    effect   proved    so   gratifying 

r§  that  this  method  became  the  rou- 

•5  tine  treatment.     The  sour  regur- 

P'S  gitation    subsides,    the    vomiting 

^  §  immediately  ceases,  the  pain  and 

■S  «  distress  after  eating,  within  a  few 

2j«  hours  to  a  few  days,  disappear, 

i2  "^  and  finally  an  increase  in  the  body 

«  g  weight  is  manifest  as  early  as  the 
first  week.     Besides,  the  improve- 


c  g  ment   is  comparatively  rapid,  so 
^'^  that  the  patient  can  be  dismissed 
2^as  cured  within  a  briefer  time  than 


formerly. 

The  following  is  the  tabulated  regimen:  "Absolute  rest  in  bed  for 
at  least  four  weeks.     All  mental  excitement  to  be  avoided.     An  ice-bag 


ULCER   OF   THE   STOMACH 


303 


is  placed  upon  the  stomach  and  kept  there  almost  continually  for  two 
weeks.  This  prevents  gaseous  distention  and  promotes  contraction  of 
the  stomach-walls,  thus  tending  to  obviate  hemorrhage,  and  eases  the 
pain  when  present.  On  the  first  day,  even  when  a  hematemesis  has 
occurred,  the  patient  receives  between  6-9  ounces  (200  and  300  c.c.)  of 
iced  milk  given  in  spoonfuls,  and  from  two  to  four  beaten  raw  eggs  within 
the  first  twenty-four  hours.  At  the  same  time  bismuth  subnitrate  is  given 
twice  or  thrice  a  day,  30  grains  (2  grams)  per  dose,  and  continued  for  ten 
days.  The  eggs  are  beaten  up  entire  (with  a  little  sugar),  and  the  cup 
containing  them  is  placed  in  a  dish  filled  with  ice,  so  that  they  remain 
cold.  This  food  at  once  'binds'  the  supersecreted  acid,  and,  therefore, 
mitigates  the  pain  rapidly  and  causes  the  vomiting,  often  quite  trouble- 
some, to  cease.  The  fat  which  is  present  in  the  egg  yolk  also  inhibits  the 
secretion  of  hydrochloric  acid.  The  portion  of  milk  is  increased  daily  per 
3  ounces  (100  c.c),  and  at  the  same  time  one  additional  egg  is  given,  so  that 
at  the  end  of  the  first  week  the  patient  is  receiving  25  ounces  (800  c.c.)  of 
milk  and  from  six  to  eight  eggs.  Both  these  foods  are  now  continued  in 
the  same  amount  pro  die  for  another  week.  No  more  than  i  liter  of  milk  a 
day  is  allowed  at  any  time.  Besides  milk  and  eggs,  some  raw  chopped 
meat  is  given  from  the  fourth  to  the  eighth  day,  usually  on  the  sixth, 
9  drams  (35  grams)  pro  die,  in  small  divided  doses  (stirred  up  with  the 
eggs  or  given  alone);  the  day  after  18  drams  (70  grams),  and  later  possibly 
more  if  well  digested.  The  patient  is  now  able  to  take  some  rice,  well 
cooked,  and  a  few  zwieback  (softened).  In  the  third  week  quite  a  mixed 
diet  is  tolerated,  the  meat  being  given  now  well  cooked  or  lightly  broiled." 

All  heavy  foods  are  interdicted,  as  well  as  vegetables  with  husks,  etc., 
and  those  tending  to  produce  flatulence.  The  patient  is  given  strict  orders 
to  masticate  his  food  thoroughly.     The  table  gives  the  daily  quantities. 

The  bowels  are  not  moved,  both  in  order  to  avoid  any  peristaltic  irri- 
tation and  to  permit  the  reabsorption  of  blood  that  may  have  passed  into 
the  intestine.  One  need  pay  absolutely  no  attention  to  constipation  in 
the  first  week,  even  in  many  cases  to  the  end  of  the  second.  After  the 
second  week  the  bowels  are  moved  with  small  glycerin  injections  or  warm 
water,  and  after  the  third  week  this  is  done  daily  if  a  movement  does  not 
occur  spontaneously.  After  this  one  tries  to  control  the  bowels  by  means 
of  the  food  and  by  getting  the  patient  to  go  to  stool  regularly. 

For  the  anemia  iron  is  given  in  the  form  of  a  soft  preparation  of 
Blaud's  pills: 

I^.    Ferri  sulphas lo.o  gm.; 

Magnesia  usta 1.75  gm.; 

Glycerinum gtt.  xxx  (3.6  gm.). — M. 

Divide  in  piluls  Ix;  2  pills  to  be  taken  two  or  three  times  a  day. 

The  pills  are  given  as  early  as  the  sixth,  eighth,  or  tenth  day  of  treat- 
ment, according  to  need,  administering  them  first  in  a  macerated  condition. 

In  severe  cases  arsenic  is  also  given  in  the  form  of  "Asiatic  pills," 
each  containing  o.oooi  gm.  of  arsenous  acid.  The  dose  is  gradually  in- 
creased, 3  for  three  days,  4  for  four  days,  up  to  7  for  seven  days,  then  de- 
creasing again,  6  for  six  days,  etc.  After  the  tenth  day  and  to  the  sixth 
week  bismuth  compositum  is  substituted  for  the  subnitrate  and  given 


304  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

three  times  a  day  before  meals.  The  patient  is  usually  allowed  up  on  the 
twenty-eighth  day  and  is  dismissed  in  the  sixth  to  the  tenth  week.  Len- 
hartz  reports  only  8  per  cent,  of  recurrent  hemorrhages  after  this  method 
of  treatment  as  compared  with  20  per  cent,  after  the  older  methods.  No 
unfavorable  results  were  produced. 

Samuel  Lambert,^  of  New  York,  and  E.  I.  Spriggs,^  of  London,  have 
reported  favorable  results. 

Senator's  Method. — Senator  has  modified  Lenhartz's  treatment,  and 
employs  a  nourishing  diet,  non-irritating,  which  tends  to  check  hemor- 
rhage. It  consists  chiefly  at  first  of  gelatin,  fat,  and  sugar.  At  first  a  10 
per  cent,  sweetened  gelatin  solution  is  given  in  tablespoonful  doses  every 
fifteen  minutes  to  two  hours.  Small  amounts  of  fresh  butter  and  cream 
are  allowed,  the  butter  given  in  small  frozen  balls  and  the  cream  beaten 
up  with  sugar  to  form  whipped  cream,  or  it  is  iced.  He  gives  daily  15 
to  20  grams  of  gelatin,  K  pint  of  cream,  and  30  grams  of  butter.  The 
daily  allowance  is  from  900  to  1000  calories,  and  may  be  begun  immediately 
after  a  hemorrhage.  Olive  oil  may  be  given  instead  of  butter.  Gelatin 
is  later  replaced  by  calves'-foot  jelly,  milk  and  eggs,  etc.  He  occasionally 
adds  rectal  feeding,  though  little  of  late.  Gradual  additions  are  made 
to  the  diet. 

Sippy',  with  gastric  or  duodenal  ulcer,  feeds  every  hour  5iii  o^  a- 
mixture  of  equal  parts  milk  and  cream  from  7  a.  m.  to  7  p.  m.;  after  two 
to  three  days  soft  eggs  and  well-cooked  cereals;  or  example,  in  addition 
to  cream  and  milk,  3  soft  eggs,  9  ounces  cereal,  each  day  of  twelve  hours. 
Cream  soups  and  vegetable  purees  occasionally  are  substituted.  Later  he 
adds  jellies,  custards,  creams,  marmalades,  etc.  The  object  should  be  a 
gain  of  two  to  three  pounds  weekly.  The  same  observer  keeps  the  gastric 
contents  neutral  all  the  time.  In  cases,  particularly  with  retention  of  gastric 
contents,  as  much  as  grs.  100  soda  bicarb,  have  been  given  every  hour  be- 
tween feedings  7  A.  m.  to  7  p.  m.  and  3  doses  J-^  hour  apart  after  8  p.  m.  Neu- 
tralize all  free  HCl  during  the  night.  Magnes.  usta  is  also  used,  but  should 
not  be  pushed  to  diarrhea.  In  cases  without  retention  of  gastric  contents 
gr.  xaa  magnes.  usta  et  soda  bicarb,  are  alternated  every  hour  with  bismuth 
subcarb.  grs.  x  -{•  soda  bicarb,  grs.  20-30  midway  between  feedings. 

Schmidt^  believes  in  the  Lenhartz  principle  of  feeding,  but  does  not 
increase  the  diet  as  rapidly.  He  gives  the  stomach  rest  a  few  days,  like 
Leube,  and  then  increases  the  diet  more  rapidly  by  giving  gelatin,  eggs, 
butter,  cream,  sugar,  and  rice;  but  chopped  meat  and  ham  with  caution. 

E.  Weiss,  of  Paris,  has  demonstrated  the  value  of  the  injection  of  fresh 
animal  serum  in  the  treatment  of  hemophilia  and  purpura,  and  Wm. 
Hanna  Thomson^  has  employed  with  success  the  injection  of  15  c.c.  of 
rabbit's  serum  hypodermically  every  day  in  a  case  of  subcutaneous  ex- 
travasation of  blood  and  of  hematuria.     Hort^  claims  success  in  arresting 

^  Trans.  Assoc.  Amer.  Phys. 

*  British  Med.  Jour.,  Apr.  3,  1909;  Med.  Chir.  Trans.,  1907,  xc,  783;  Proc.  Roy. 
Soc.  Med.,  1909,  ii,  iii;  Therap.  Sect.,  81;  and  British  Med.  Jour.,  May  21,  1910. 

'Journal  A.  M.  A.,  May  15,  1915. 

*  Deutsch.  med.  Woch.,  Jan.  r8,  1906. 
'  N.  Y.  Med.  Jour.,  June  11,  1910. 

*  Brit.  Med.  Jour.,  Jan.  5,  1910,  p.  75;  ibid.,  Oct.  lo,  1909. 


ULCER  OF  THE   STOMACH 


305 


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306  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

severe  hematemesis  by  administering  normal  horse-serum  by  mouth, 
and  also  excellent  results  in  the  treatment  of  gastric  ulcer  without  hemor- 
rhage, with  the  subsidence  of  pain  and  vomiting.  He  begins  with  lo  to 
15  c.c.  of  sterile  horse-serum,  daily  increasing  it  until  no  less  than  30  c.c. 
are  taken  each  day.  The  serum  is  administered  by  mouth  in  milk  or  in 
half  an  ounce  to  an  ounce  of  water,  and  never  on  an  empty  stomach. 
If  the  pain  is  severe  or  there  is  hemorrhage,  from  60  to  80  c.c.  may  be 
given  in  twenty-four  hours.  The  treatment  should  continue  for  six 
weeks  or  longer,  and  preferably  for  some  weeks  after  apparent  cure.  This 
same  treatment  is  employed  for  duodenal  ulcer.  Hort  employs  serum  treat- 
ment for  chlorosis  and  externally  locally  for  ulcers  of  the  leg.  Hort's 
dietetic  treatment  follows  the  lines  of  Lenhartz.  Levison^  reports  the 
local  styptic  effect  of  horse-serum  in  hemorrhage  following  operation  on 
the  gall-bladder  and  bladder. 

My  own  method  depends  upon  whether  I  first  treat  the  patient  during 
the  period  of  hemorrhage  or  later. 

If  the  hemorrhage  is  taking  place  or  has  just  occurred,  i  to  2  drams 
(4.0-8.0),  of  a  5  to  10  per  cent,  solution  of  sweetened  gelatin  is  given  cold 
every  half  hour  for  ten  to  twelve  hours,  even  if  there  be  vomiting.  During 
the  remaining  period  of  the  first  twenty-four  hours  the  gelatin  is  con- 
tinued, 3-^  to  I  ounce  (16.0-32.0),  every  two  to  three  hours  while  the  pa- 
tient is  awake,  and  in  addition  the  whites  of  two  raw  eggs  are  beaten  up  and 
placed  in  a  cup  on  ice  and  given  in  divided  doses.  An  ice-bag  is  kept  on 
for  at  least  two  weeks  if  hemorrhage  has  just  occurred.  The  addition 
of  horse-serum  according  to  Hort's  method  the  writer  believes  justifiable, 
or  the  use  of  human  blood-serum  by  hypodermic. 

Gelatin  treatment  is  continued  for  a  week.  Scraped  beef  and  ham  are 
omitted  for  the  first  two  weeks  and  cream  substituted,  to  obtain  the  calorie 
values.     A  little  sugar  can  be  beaten  up  with  the  cream. 

The  day  following  the  hemorrhage  milk  is  begun,  6  ounces  (200  c.c.) 
cold,  in  spoonful  doses,  100  grams  (10  per  cent,  gelatin  solution)  cold, 
in  divided  doses — ^i  ounce  (16.0) — every  three  hours,  and  one  raw  egg 
beaten  up  and  given  in  divided  doses.  These  are  placed  in  cups  which 
are  packed  in  ice.  The  milk  is  increased  100  c.c.  daily  up  to  1000  c.c, 
and  no  more;  eggs  are  increased  daily  one  egg  up  to  eight  a  day.  With 
the  exceptions  noted,  the  rest  of  the  diet  is  after  Lenhartz  for  the  two 
weeks.     Purees  and  various  cereals  are  then  added. 

I  give  no  scraped  beef  until  the  commencement  of  the  third  week 
after   hemorrhage,   and   then   increase   the   diet   after  Leube's   method. 

If  no  recent  hemorrhage,  I  start  the  diet  after  the  method  correspond- 
ing to  the  third  day  in  the  table  on  page  305.  An  ice-bag  is  kept  on  for 
two  weeks  if  there  is  hemorrhage  or  one  has  occurred  within  a  week  or 
ten  days. 

The  patient  should  increase  in  weight  2  to  3  pounds  per  week  during 
the  four  weeks  rest  cure. 

Bismuth  subnitrate,  K-i  dram  (2.0  to  4.0),  is  given  in  2  ounces  (60.0) 
water  t.i.d.  before  feedings,  commencing  on  the  day  after  hemorrhage. 

• 
•  Journal  A.  M.  A.,  Mar.  8,  1913. 


ULCER   OF  THE   STOMACH  307 

At  times  I  combine  magnesia  usta,  15  grains  (i.o),  or  sodium  bicarbonate, 
15  grains  (i.o),  with  the  bismuth. 

Pain. — This  may  be  caused  by  the  hyperacid  condition  of  the  gastric 
contents  irritating  the  ulcer  or  frequently  by  gastric  spasm.  Tincture 
belladonna,  10  gtts.  (0.66)  in  a  teaspoonful  of  water  should  be  given 
t.i.d.  for  pain  and  spasm.  It  also  lessens  gastric  secretion  and  motility, 
and  is  a  valuable  adjunct  to  the  treatment.  At  times  a  fourth  dose  may  be 
indicated.  It  further  lessens  the  tendency  to  vomiting  and  hemorrhage 
by  diminution  of  the  motility  and  of  hypersecretion.  Stockton^  has 
employed  hypodermic  injection  of  i  c.c.  adrenalin  solution  (1:1000) 
successfully  in  several  cases  of  gastric  and  pyloric  spasm.  Orthoform  or 
anesthesin,  of  which  the  dose  is  5  grains  (0.3)  is  also  recommended  for 
the  pain  of  ulcer.  They  are  of  some  value,  but  as  excessive  acidity  and 
increased  motility  have  the  most  influence  in  these  ulcer  cases  in  aggra- 
vating the  pain,  belladonna  seems  of  most  value.  Extract  of  belladonna, 
}i  grain  (0.22),  or  atropin,  Hoo-Ho  grain  (0.0006),  may  be  substituted 
for  the  tincture  of  belladonna. 

Rarely  a  hypodermic  of  K  to  >^  grain  (0.016-0.032)  of  codein  or 
morphin,  ^i  to  H  grain  (0.008-0.016),  may  be  necessary  for  the  acute 
pain. 

Bowels. — I  prefer  to  move  the  bowels  gently  by  a  small  soapsuds 
enema  containing  2  ounces  (60.0)  of  olive  oil  on  the  third  day  after  hemor- 
rhage, and  thereafter  every  other  day.  If  no  hemorrhage  has  occurred 
recently,  then  a  daily  movement  should  be  secured.  Milk  of  magnesia, 
I  to  2  drams  (4.0-8.0)  in  4  ounces  (125.0)  water,  given  on  rising,  or  small 
doses  of  Sprudel  salts,  i  dram  (4.0)  in  a  glass  of  hot  water,  are  of  service. 

On  the  seventh  day  after  hemorrhage,  or  immediately  if  there  has 
been  no  hemorrhage,  iron  and  arsenic  should  be  given: 

I^.  Blaud's  iron  pill gr.  v  (0.3)  (made  fresh); 

Sod.  arsen gr.  ).^o  (o-ooi3). 

Pill  made  soft  with  honey  and  crumbled  when  taking,  one  pill  t.i.d.  after 
eating.  The  arsenic  can  be  gradually  increased  to  gr.  J.^5  (0.0026)  sod. 
arsen.  t.i.d. 

The  bismuth  treatment  should  be  continued,  or  one  can  substitute  the 
nitrate  of  silver  treatment.  It  is  advisable  to  keep  this  up  for  several 
months  as  a  precaution,  and  then  continue  the  diet  and  alkaline  treatment 
for  hyperchlorhydria  for  a  considerable  period. 

At  the  end  of  three  weeks  the  patient  may  be  allowed  to  sit  up  for 
a  short  time  daily;  and  at  the  end  of  four  weeks  to  begin  to  go  outdoors 
for  a  short  time.  In  favorable  cases  it  is  advisable  not  to  resume  work 
under  six  weeks  after  bed  treatment.  Some  of  the  cases  either  will  not 
remain  in  bed  or  cannot,  for  financial  reasons,  particularly  if  there  is  no 
hematemesis. 

In  such  event,  we  are  obliged  to  employ  careful  but  liberal  feeding; 
the  use  of  Carlsbad  salts,  iron  and  arsenic  tonics,  and  either  the  subnitrate 
of  bismuth  treatment  with  an  alkali  in  addition,  or  nitrate  of  silver.  The 
following  prescriptions  are  of  service: 

•  N.  Y.  State  Journal  of  Medicine,  October,  1913. 


3o8  DISEASES   OF   THE   STOMACH  AND   INTESTINES 

I^.     Bismuth  subnitrate 5iv.; 

S 2. o  to  4.0  (3ss-j). 

Stirred  in  4  ounces  (125  c.c.)  of  water,  given  t.i.d.  half  an  hour  before  meals. 

This  is  preferable  to  pouring  the  bismuth  suspension  through  a  stomach- 
tube. 

As  olive  oil  protects  the  surface  and  lessens  the  secretion,  I  some- 
times employ  the  bismuth  suspended  in  i  to  2  ounces  (30.0-60.0)  of  olive 
oil  instead  of  water.  Alkalis  should  also  be  used.  Mineral  oil  has  been 
advocated  as  a  carrier  for  the  bismuth. 

I^.  Magnesia  usta 2.0  (gr.  xxx),  or 

Milk,  of  magnesia 4.0  to  8.0  (3j-ij)- 

In  3  or  4  ounces  (100-125  c.c.)  of  water  alone,  or  combined  with  equal 
quantities  of  soda  bicarbonate. 

R.  Soda  bicarb.       1  ..,-..    ^ 

TV,  .         ,     I aa  lo.o  (5iiss); 

Magnesia   usta  J  "        ' 

Milk-sugar 2.0  (3ss). 

Dose,  2.0  (3ss)  in  water  t.i.d.  an  hour  after  eating. 

Nitrate  of  silver  can  be  employed  in  place  of  the  bismuth,  to  be  given 
on  an  empty  stomach  t.i.d.  half  an  hour  before  meals,  as  advocated  by 
Boas  and  Kaufmann: 

I^.  Argenti  nitratis 0.2  (gr.  iij); 

Aq.  destil 180.0  (5  vj). 

Keep  in  dark  bottle.     Tablespoonful  in  wineglass  of  water  t.i.d.  half  an 
hour  before  eating. 

Occasionally  lavage  of  the  stomach  with  1:5000  to  1:3000  silver 
nitrate  or  protargol  or  argyrol  i  :  2500  has  been  advocated  once  or  twice  a 
week,  if  there  has  not  been  a  hemorrhage  for  some  weeks.  The  internal 
administration  of  silver  nitrate  is  usually  preferable.  It  should  be  given 
for  two  to  three  weeks,  then  discontinued  and  the  bismuth  substituted. 

The  alkali  can  be  given  in  addition  t.i.d.  an  hour  after  meals.  The 
meals  should,  preferably,  be  frequent  and  in  smaller  quantities,  as  in 
hyperchlorhydria. 

Stenosis  with  Dilatation. — In  cases  complicated  by  stenosis  and  ectasia 
surgery  is  always  indicated.  Temporarily  lavage,  particularly  at  night  so 
the  stomach  will  be  empty,  is  necessary  for  the  fermentation,  and  olive 
oil,  I  to  2  ounces  (30.0-60.0)  t.i.d.  before  the  chief  meals,  to  aid  the  passage 
of  food.  The  application  of  Rose's  belt,  and  the  patient  lying  on  the  right 
side  for  half  an  hour  after  eating,  both  temporarily  aid  in  emptying  the 
stomach. 

Resorcin  in  5-grain  (0.3)  doses  t.i.d.  is  also  of  value  for  the  fermenta- 
tion. Wm.  H.  Thomson^  advocates  the  use  of  resorcin  and  also  potas- 
sium bichromate  in  gastric  ulcer.  His  formulae  are  found  on  page  260 
under  treatment  of  Chronic  Catarrh  of  the  Stomach.  The  writer  prefers 
the  omission  of  the  nux  and  ginger  in  the  ulcer  cases. 

Hemorrhage  is  rare  in  this  type,  the  ulcer  being  dormant  and  the  chief 
symptoms  due  to  stenosis.  Surgery,  resection  of  the  ulcer  with  gastro- 
enterostomy especially,  is  advocated  in  these  cases.  If  there  is  tetany, 
the  same  procedure  is  advisable. 

1  N.  Y.  Med.  Jour.,  June  11,  1910. 


ULCER    OF   THE    STOMACH 


309 


Hypersecretion. — This  should  be  treated  by  lavage  about  10  a.  m., 
following  the  same  by  atropine  Hoo-Ko  and  an  alkali. 

Vomiting. — In  cases  described  by  Lenhartz,  this  is  relieved  by  neutral- 
izing the  acid,  and  this  is  the  best  treatment.  Rarely,  rectal  feeding  may 
be  required  for  a  few  days.  Bismuth  subnitrate,  2  grains  (0.13),  and 
oxalate  of  cerium,  i  grain  (0.065),  should  be  given,  or  i-drop  doses  of 
Fowler's  solution  of  arsenic,  four  in  all,  an  hour  apart.  If  the  vomiting 
continue,  a  single  cautious  lavage  is  a  safer  procedure  than  the  risk  of 
recurrent  hemorrhage  from  the  strain  of  emesis. 

Tincture  of  belladonna,  10  gtts.  (0.66),  or  atropin,  Hoo-Ho  grain 
(0.0060),  are  also  of  service  for  the  vomiting. 

Pain  from  Adhesions. — Rose's  belt  will  at  times  aid  in  alleviating  the 
pain  due  to  the  dragging  of  adhesions,  by  the  support  afTorded  to  the 
viscera.  Bacterial  vaccines  have  been  employed  to  treat  the  ulcer.  On 
account  of  Tiirck's  experiments  in  producing  gastric  ulcer  in  dogs  by  the 
ingestion  of  colon  bacilli,  a  weekly  dose  of  bacterial  vaccines,  40,000,000 
each,  has  been  advocated  by  Aaron  for  the  treatment  of  gastric  ulcer. 

X-rays. — Bassler^  advocates  the  employment  of  the  x-Ta.y5  for  the 
healing  of  gastric  ulcer,  but  I  am  skeptical  of  their  value  on  the  internal 
organs  for  such  purpose.  In  cutaneous  affection.s  they  are  undoubtedly 
of  value.     Their  prolonged  use  is  also  dangerous. 

Perforation. — Temporarily,  rectal  feeding,  a  hypodermic  of  morphin, 
the  ice-bag,  and  cautious  lavage  after  cocainizing  the  pharynx,  as  sug- 
gested by  Ewald,  are  indicated.  Immediate  recourse  should  be  had  to 
laparotomy. 

Surgery. — The  following  are  the  indications  for  operation:  Perfora- 
tion with  commencing  peritonitis;  local  peritonitis,  .with  or  without 
abscess;  subphrenic  abscess;  perigastric  adhesions]  ectasia  due  to  stenosis 
from  ulcer  or  spasm  from  its  irritation;  gastric  tetany  with  ulcer. 

In  recurring  acute  hemorrhages  the  Mayos  advise  opening  the  stomach, 
locating  the  bleeding  point,  suturing  it  firmly  with  catgut  on  the  inner 
(mucous)  side,  and  protecting  the  region  by  mattress  sutures  (musculo- 
peritoneal).     Gastrojejunostomy  they  have  not  found  reliable. 

In  six  cases — ">ne  case  of  death  from  hemorrhage  followed  gastrojeju- 
nostomy— five  cases  treated  by  primary  operation  on  the  bleeding  point, 
with  or  without  excision  of  the  ulcer,  recovered.^ 

Rovsing,  in  cases  of  severe  hemorrhage,  employs  direct  diaphanoscopy 
and  gastroscopy  (the  light  introduced  through  a  minute  incision  in  the 
stomach- wall).  The  writer's  new  inflating  gastroscope  is  a  more  practical 
instrument  for  this  purpose.  After  locating  the  source  of  hemorrhage, 
it  is  obliterated  by  running  a  suture  about  the  bleeding  surface.  Kraft' 
reports  five  cases. 

In  cases  of  ulcer,  with  one  or  more  recurrent  hemorrhages,  after 
systematic  medical  treatment  for  six  months  by  the  methods  I  have  de- 
scribed, if  the  patient  is  uncured,  I  advocate  resort  to  surgery.     An  ulcer 

*  Diseases  of  the  Stomach  and  Upper  Alimentary  Tract,  Med.  Times,  Sept.,  1909. 
'Jour.  Amer.  Med.  Assoc,  Sept.  22,  1906. 

'  Archiv  fur  Klinische  Chir.,  Berlin,  xciii,  No.  3,  pp.  557-789.  Last  indexed, 
Nov.  19,  p.  1850.     L.  Kraft,  Zur  Behandlung  der  lebensgafahrlichen  Magenblutungen. 


3IO  DISEASES   OF  THE   STOMACH   AND  INTESTINES 

uncured  by  six  months  medical  procedure,  I  believe  to  be  of  chronic  type 
and  that  surgical  procedure  is  indicated.  I  am  aware  that  some  surgeons 
are  loath  to  operate  on  such  cases  unless  there  is  pyloric  stenosis,  and  claim 
that  in  such  event  the  gastric  contents  will  not  pass  through  the  new 
opening,  but  through  the  pylorus.  Canon  and  Blake  have  demonstrated 
this  experimentally  on  animals.  On  the  other  hand,  when  a  large  anas- 
tomotic opening  is  made,  this  has  been  shown  to  be  of  practical  value,  at 
least  for  a  time,  especially  by  the  posterior  no-loop  method. 

It  has  been  demonstrated  that  the  pancreatic  juice  and  bile  entering 
the  stomach  aid  in  neutralizing  the  hyperacidity,  and  this  is  of  service. 

Wm.  Mayo  states  that  in  chronic  ulcer,  where  there  is  no  mechanic 
obstruction,  the  result  has  not  been  as  favorable.  Unfortunately,  we 
do  find  cases  of  multiple  ulcers  with  hemorrhages  from  various  areas  and 
with  an  open  and  soft  pylorus,  such  as  Munro^  reports,  in  which  the 
results  of  surgery  are  not  favorable;  but  in  any  event  the  lessening  of 
hyperacidity  through  gastro-enterostomy  is  of  value.  Excision  of  the 
ulcer  is  indicated  when  possible. 

With  a  patent  pylorus,  however,  the  anastomosis  will  at  times  close.  In 
Figs.  185,  186,  and  187,  an  interesting  case  is  demonstrated.  This  patient 
was  operated  on  for  ulcer  of  the  body  of  the  stom.ach,  by  gastro-enterostomy, 
the  pylorus  being  patent  at  time  of  operation  presumably.  The  wound 
became  infected  and  broke  open.  He  came  to  me  suffering  from  epi- 
gastric burning  two  hours  after  meals  and  for  me  to  examine  the  hernia 
which  had  developed  at  the  site  of  the  old  incision.  There  was  hyper- 
acidity— but  no  blood.  There  was  no  vomiting.  Radiographs  show  (Fig. 
185)  stomach  slightly  distended  (hardly  dilated)  with  deep  incisura 
at  -{-.  Fig.  186;  marked  bismuth  retention  six  hours  later — irregular 
streaks  of  bismuth  passing  upward — no  vomiting — no  symptoms  of 
stenosis — stomach  normal  position.  Adhesions  believed  responsible  for 
disturbance  of  motility,  at  +  an  incisura  believed  to  correspond  probably 
to  stoma  of  gastro-enterostomy.     No  bismuth  escape  noted. 

In  Fig.  187  is  also  a  radiograph  six  hours  after  bismuth  by  mouth,  but 
after  bismuth  enema.  The  stomach  is  forced  up  slightly  higher.  The 
same  bismuth  retention  and  incisura  are  noted. 

Operation  by  Wm.  P.  Healy  demonstrated  marked  adhesions  between 
anterior  surface  of  the  stomach  and  the  abdominal  wall,  liver  and  spleen — 
thus  accounting  for  disturbance  of  motility  and  bismuth  retention.  No 
pyloric  stetwsis — perfectly  patent,  evidences  of  an  old  ulcer  in  the  body 
of  the  stomach  now  healed.  A  band  occupied  the  position  of  a  former 
gastro-enterostomy  opening.  The  stomach  and  intestine  were  separated 
b.y  the  operator.  Only  the  finest  probe  could  be  passed  through  this 
band  into  the  stomach.     Adhesions  were  separated  and  the  hernia  closed. 

With  chronic  ulcer  at  the  pylorus,  pylorectomy  and  gastro-enteros- 
tomy give  the  best  results.  The  writer  now  believes  that  in  the  case  of 
chronic  gastric  ulcer  or  ulcers  (extra-pyloric)  which  it  may  be  advisable 
to  excise,  that,  in  addition  to  the  gastro-enterostomy,  infolding  the  stomach 
on  the  gastric  side  of  the  pylorus  should  be  performed,  thus  closing  the 
pyloric  orifice.  The  gastric  contents  must  then  of  necessity  pass  through  the 
^  Annals  of  Surg.,  June,  1907. 


ULCER   OF   THE   STOMACH 


311 


Fig.  185. — Case  of  epigastric  hernia.  Old  history  of  ulcer  with  gastro-enterostomy. 
Slight  distention  of  stomach.  Incisura  at  +■  Indentations  above  at  pyloric  end 
somewhat  irregular,  believed  to  be  due  to  adhesions.  No  vomiting,  no  symptoms  of 
pyloric  stenosis.     The  incisura  is  stoma,  no  longer  patent. 


Fig.  186.  Fig.  187. 

Fig.  186. — Same  case  as  Fig.  185  si.\  hours  after  bismuth  meal,  before  enema.  Marked 
retention  of  bismuth,  irregular  contour  above.  Incisura  at  +  believed  to  be  site  of 
old  gastro-enterostomy  opening,  but  no  bismuth  passes  out,  no  vomiting.  Stasis 
shown  at  operation  to  be  due  to  adhesions,  pylorus  patent,  ulcer  of  body  of  stomach 
heated.  Stoma  of  gastro-enterostomy  opening,  no  longer  patent  for  food,  reduced  to 
pin-head  opening. 

Fig.  187. — Same  case  as  Fig.  185  six  hours  after  bismuth  meal  and  after  bismuth 
enema.  Stomach  pushed  up  slightly,  normal  position.  Bismuth  retention  marked 
below,  streaked  above.  No  vomiting.  Retention  believed  to  be  due  to  adhesions 
interfering  -with  mobility  and  that  pylorus  is  patent.  Incisura  at  +  believed  to  represent 
old  stoma  of  gastro-enterostomy  with  no  bismuth  escape.     Proved  correct  at  operation. 


312  DISEASES  OF  THE  STOMACH  AND  INTESTINES 

gastro-enter ostomy  opening.  The  same  method  would  be  useful  in  some 
cases  of  pyloric  spasm. 

A.  Berg^  ingeniously  employs  an  occluding  purse-string  ligature 
just  proximal  to  the  antrum.  Among  other  methods  advocated  are 
unilateral  pyloric  exclusion,  blocking  the  pylorus  by  means  of  winding  a 
strip  from  the  sheath  of  the  rectus  abdominis  about  it;  while  Charles 
Mayo  uses  a  strip  of  tissue  from  the  gastro-hepatic  or  greater  omentum 
leaving  it  attached  at  its  gastric  end. 

Peck^  states  that  he  has  collected  a  number  of  rontgenographic  ob- 
servations, some  of  them  four  years  after  gastro-enterostomy,  which  show 
the  openings  of  the  latter  still  functionating  through  the  pylorus  was 
patent  in  these  cases.  He  does  not  believe  one  can  draw  deductions  from 
animal  experimentation  in  this  regard.  Kuttner,^  in  the  study  of  iioo 
cases  of  gastro-enterostomy  by  late  rontgenoscopy,  states  that  the  func- 
tioning of  the  stoma  was  excellent  except  in  a  few  cases.  He  believes  it 
functionates  even  with  an  open  pylorus.  Hartmann^  holds  the  same  view 
reporting  animal  experiments  and  rontgenoscopies.  He  states,  however, 
that  it  remains  open  when  the  stoma  is  at  the  pyloric  antrum.  In  view 
of  the  practical  demonstration  in  Figs.  185-187,  it  would  seem  to  the 
writer  that  pyloric  closure  would  he  preferable. 

Excision  of  the  ulcer  in  chronic  cases,  I  now  believe  the  safest  procedure. 
This  is  especially  true  in  view  of  the  frequent  occurrence  of  cancer  engrafted 
on  gastric  ulcer.  Prophylaxis  of  gastric  cancer  can  be  aided  by  ulcer  ex- 
cision, as  Wilson  and  MacCarty  have  shown  that  71  per  cent,  of  cancers 
had  their  origin  in  chronic  gastric  ulcer  (Mayo).^  Coffey^  excised  the 
entire  lesser  curvature  in  a  case  of  ulcer  with  success.  W.  L.  Rodman 
further  advocates  pylorectomy  in  chronic  gastric  ulcer  to  prevent  later 
cancerous  implantation  on  the  base  of  the  ulcer.  Moreover,  the  danger 
of  hemorrhage,  adhesions,  etc.,  are  thus  eliminated. 

In  cases  of  pyloric  obstruction  (stenosis)  from  ulcer  with  dilatation  of  the 
stomach,  I  always  advocate  surgical  procedure,  finding  that  though  there 
may  be  temporary  improvement,  at  times  quite  marked  under  medical 
treatment,  in  every  case  there  is  subsequent  relapse. 

Gastrojejunal  and  Jejunal  Ulcers. — One  must  remember  the  pos- 
sibility that  after  gastrojejunostomy  for  gastric  ulcer  a  secondary  ulcer 
occasionally  occurs  in  the  intestinal  loop  or  at  the  gastrojejunal  junction. 
A  unique  case  of  this  type  is  reported  by  J.  F.  Percy,  in  the  Journal  of 
the  American  Medical  Association,  April  9,  1910,  a  recurrent  ulcer  per- 
forating at  the  gastro-intestinal  (anterior  gastrojejunostomy)  anas- 
tomoses. An  omental  adhesion  prevented  peritonitis.  A  posterior 
operation  was  then  performed.  Percy  believes  that  infection  from  chronic 
cholecystitis  is  a  factor  in  these  cases.  Dunham,  in  the  November  10, 
1910,  issue  of  the  same  journal,  gives  some  interesting  statistics  on  gastro- 
enterostomy. 

^  Journal  A.  M.  A.,  p.  883,  Mar.  22,  1913. 
''Journal  A.  M.  A.,  Aug.  12,  1915. 
^  Arch.  f.  klin.  chir.,  1914,  cv,  789. 

*  Annals  Surgery,  1914,  lix,  835. 

*  Jour.  Amer.  Med.  Assoc,  May  14,  1910,  p.  1609. 
*Ibid.,  Sept.  10,  1910  (Wilson  and  Willis);  Jan.  28,  1911. 


ULCER    OF   THE    STOMACH 


313 


William  J.  Mayo^  calls  attention  to  the  development  of  gastrojejunal 
ulcer  at  the  site  of  anastomosis  and  attributes  the  ulcer  in  some  cases 
to  irritation  by  a  silk  suture  which  may  remain  hanging  in  the  wound, 
advising  therefore  very  fine  silk  sutures.  Pressure  ulcer  from  impaction 
of  a  Murphy  button,  retention  of  infected  suture  material  and  infected 
hematoma  have  been  reported  as  causes. 

Jejunal  Ulcers. — A  single  ulcer  is  the  rule  generally  occurring  near 
the  anastomosis. 

Etiology. — Hyperacidity  has  been  considered  the  cause  in  most  cases 
and  in  others  hypersecretion.  Among  other  causes  are  contraction  of  the 
jejunum  below  the  anastomosis  with  stagnation  above  it,  traumatism 
at  the  time  of  operation,  disturbance  of  circulatory  conditions  due  to 
abnormal  position  of  the  loop,  and  infective  origin. 

Symptoms. — The  first  symptom  may  be  perforation.  In  other  cases 
after  temporary  relief  by  operation,  epigastric  pain  will  recur,  generally 
two  to  four  hours  after  meals  and  not  relieved  by  food;  the  pain  is  often 
lower,  usually  to  the  left  of  the  midline  and  below  the  umbilicus — occa- 
sionally soda  bicarbonate  is  of  benefit.  Gastric  analysis  usually  shows 
hyperacidity  but  not  always,  and  occult  blood  is  present,  and  is  usually 
also  found  in  the  stools.  Tenderness  may  be  present.  Hemorrhage  may 
occur  with  black  tarry  stools.  Many  of  the  old  symptoms  of  gastric 
ulcer  recur.  Perforation  may  occur  into  the  peritoneal  cavity  through 
the  abdominal  wall  or  into  the  colon. 

Radiology. — Carman  and  Balfour^  note  the  following  radiological  find- 
ings under  normal  conditions  following  gastroenterostomy. 

1.  The  opaque  meal  passes  freely  through  the  stoma.     This  is  the 
rule,  subject  to  occasional  exceptions,  even  after  the  lapse  of  years. 

2.  No  retention  is  present  in  the  stomach  from  the  six-hour  meal. 

3.  The  duodenum  is  not  dilated. 

4.  The  stomach  is  usually  small. 

5.  Peristalsis  is  not  overactive. 


RoNTGEN  Findings  in  Eleven  Cases  of  Gastro-jejunal  Ulcer 


R6ntgen-ray  findings 

• 
Case  number 

S0276 

83614 

81306 

76684 

98939 

12869 

69645 

96667 

IISSS3 

101624 

131378 

Deformity  about  stoma. . 
Exaggerated  peristalsis.  . 
Large  stomach 

+ 
+ 
+ 

+ 

+ 

+ 

+ 

+ 

+ 
+ 

+ 

+ 
+ 

+ 
+ 

+ 
Mod. 

+ 

+ 

Aver. 
Mod. 

4- 
+ 
+ 

+ 

+ 
+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

Mod. 

+ 

Gastro-enterostomy   not 
freely  patent 

Retention  from  six-hour 
meal 

Lessened      mobility      of 
stomach 

Dilatation  of  duodenum. 

Spasticity  of  stomach 

Irregularity  of  jejunum . . 

'  Boston  Med.  and  Surg.  Jour.,  Jan.  29,  1914. 
^Journal  A.  M.  A.,  July  17,  1915. 


314  DISEASES   OF  THE   STOMACH   AND  INTESTINES 

6.  The  gastric  contour  in  the  vicinity  of  the  stoma  is  not  usually 
deformed,  save  for  a  slight  dimpling  at  that  point  occasionally. 

7.  The  efferent  limb  of  the  jejunum  is  neither  narrowed  nor  markedly 
irregular  in  outline. 

8.  Extensive  adhesions  about  the  stoma  simply  as  a  result  of  opera- 
tion are  uncommon,  and  the  stomach  is  at  least  moderately  mobile. 

9.  The  stomach  is  not  deformed  (unless  by  the  original  lesion  or  its 
resection)  and  has  no  tendency  to  hour-glass  form  or  spasticity. 

Noteworthy  is  the  fact  that  of  the  eleven  patients  examined  ten  showed 
abnormaUties  not  customarily  seen  in  the  gastro-enterostomized  stomach. 

Prognosis. — This  is  grave. 

Treatment. — Ulcer  cure  may  be  tried  for  a  brief  period,  but  surgical 
procedure  should  preferably  be  instituted. 

EXULCERATIO   SIMPLEX  (DIEULAFOY)   OR  SUPERFICIAL  ULCERA- 
TION OF  THE  STOMACH 

Small  ulcerations  of  the  mucous  membrane  of  the  stomach,  so  minute 
that  they  appear  to  be  little  more  than  erosions,  have  been  observed,  from 
which  fatal  hemorrhage  has  taken  place. 

The  usual  symptoms  of  ulcer  have  been  absent  and  no  vomiting 
occurred  prior  to  the  hemorrhage.  On  the  other  hand,  symptoms  of 
hyperacidity  may  be  present. 

Dieulafoy  was  the  first  to  minutely  describe  this  affection. 

Anatomy. — There  is  a  superficial  round  or  elliptic  loss  of  substance, 
involving  merely  the  mucous  membrane  and  the  muscularis  mucosae 
and  some  blood-vessels.  It  does  not  penetrate  further  into  the  coats 
of  the  organ.  The  defect  may  be  from  pinhead  size  to  a  quarter  of  a 
dollar  in  dimension;  the  margins  are  not  indurated,  and  it  may  be  difficult 
to  detect  even  on  autopsy,  being  concealed  in  some  of  the  folds  of  the 
mucous  membrane.  The  stomach  is  healthy  throughout.  There  may 
be  a  slightly  reddened  zone  about  the  area  and  it  may  be  in  any  location. 

Etiology  is  unknown.  It  may  be  the  beginning  of  an  ordinary  ulcer, 
or  possibly  a  toxic  element  is  responsible. 

Age. — Chiefly  in  persons  from  twenty-five  to  thirty. 

Symptoms. — The  patient  may  be  in  perfect  health,  when  he  suddenly 
vomits  3-^  liter  (o.i)  to  i  quart  (liter)  of  blood,  accompanied  by  melena. 
The  hemorrhage  may  prove  fatal.  The  symptoms  are  those  of  any  hemor- 
rhage: dizziness,  cold  extremities,  collapse,  and  the  patient  may  become 
rapidly  moribund.  Occasionally  the  patient  may  recover  and  suffer 
from  recurrences.  On  the  other  hand,  Dieulafoy  holds  that  a  case  repre- 
senting severe  symptoms  of  hyperacidity,  but  sfiowing  actual  subacidity, 
should  always  suggest  exulceratio  simplex  ventriculi. 

Diagnosis. — Ordinary  cases  of  gastric  ulcer  suffer  from  gastric  symp- 
toms, while  these  cases  may  not. 

From  latent  ulcer  of  the  stomach  it  cannot  be  differentiated. 

With  chronic  erosions  there  are  no  hemorrhages.  With  achlorhydria , 
haemorrhagica  gastrica,  the  gastric  findings  are  typic  and  the  condition  is 
secondary  to  other  disease. 


GASTRIC  EROSIONS  315 

Treatment. — This  is  the  same  as  in  hematemesis  from  ulcer,  morphin, 
\i  grain  (0.016);  ice-bag  over  stomach;  10  per  cent,  gelatin  solution  every 
half  hour,  2  drams  (8.0)  by  mouth;  lactate  of  calcium,  10  grains  (0.66), 
by  mouth  and  by  rectum;  ergot,  injections  of  human  blood-serum  by  hypo- 
dermic or  horse-serum  by  mouth,  hypodermoclysis  (2  per  cent,  gelatin), 
also  of  saline  solution,  etc. 

Dieulafoy  recommends  operative  procedure,  suturing  the  bleeding 
point  if  medical  remedies  fail  or  if  the  hemorrhages  are  recurrent.  The 
author's  inflating  gastroscope  would  be  of  value  to  locate  the  erosion. 

GASTRIC  EROSIONS 
These  are  subdivided  into  acute  erosions  and  chronic  erosions. 

Acute  Erosions  (Hemorrhagic  Erosions) 

These  are  small  (2  to  4  mm.)  abrasions  of  the  mucosa  of  the  stomach, 
in  character  usually  multiple,  and  extend  partly  or  through  the  layer.  In 
the  early  stages  there  are  hemorrhages  into  the  substance  of  the  mucosa 
which  appear  as  purplish  brown  or  blackish  spots,  later  becoming  digested, 
showing  small  eroded  areas.  Often  they  are  difl&cult  to  find  at  post- 
mortem, lying  between  the  folds  of  the  mucosa.  There  is  hemorrhage 
(hematemesis)  with  this  type  with  its  symptoms  preceded  at  times  by 
pain. 

Etiology. — They  occur  in  the  newborn;  in  the  cachexia  of  children; 
in  chronic  heart  and  arterial  diseases;  cirrhosis  of  the  liver;  in  acute  in- 
fections with  the  pneumococcus  (Dieulafoy),  and  with  septic  organisms 
also  in  postoperative  cases,  such  as  after  appendicitis  operation  (vomito- 
negro-appendiculaire).  Retrograde  embolism  resulting  from  detached 
thrombi  from  veins  ligated  in  the  omentum  or  mesentery  has  been  con- 
sidered a  cause  of  erosions  and  they  are  found  associated  with  the  throb- 
bing aorta  in  a  considerable  number  of  neurotic  women.  Muscular 
contraction  with  pylorospasm  associated  with  hyperacidity — secondary 
to  gall-bladder  or  appendical  infection  have  been  considered  causes; 
though  the  toxic  element  from  these  infected  organs  would  seem  to  the 
writer  the  more  likely  cause.  Such  contractions  and  formation  of  erosions 
have  been  considered  a  result  of  vagotonia. 

Treatment  is  that  of  hematemesis  and  also  of  the  cause. 

Chronic  Erosions  (Erosions  of  the  Stomach) 

An  erosion  is  a  small  superficial  exfoliation  of  the  gastric  mucous 
membrane.  Erosions  of  the  stomach  have  been  quite  frequently  found 
at  autopsy,  and  the  subject  has  been  discussed  by  Virchow,  Ewald, 
Gerhart,  and  others.     The  latter  found  nothing  characteristic. 

Riegel  notes  the  frequency  with  which  small  fragments  of  mucous 
membrane  are  washed  out  of  the  stomach,  and  believes  it  due  to  the 
tearing  from  this  procedure.  He  denies  its  significance  as  a  special 
pathologic  process,  but  believes  that  at  times  an  examination  of  the 
fragments  will  demonstrate  the  general  condition  of  the  mucous  membrane. 

There  is  even  to-day  some  dispute  as  to  whether  the  erosions  of  the 


$l6  DISEASES   OF   THE   STOMACH  AND  INTESTINES 

Stomach  can  be  described  as  a  separate  clinical  entity,  in  view  of  the  fact 
that  in  the  majority  of  cases  there  is  a  chronic  gastritis,  and  only  on  lavage 
the  bits  of  mucous  membrane  are  secured,  some  believing  it  to  be  due  to 
manipulation  with  the  tube. 

We  must  credit  Einhorn^  with  first  describing  erosions  of  the  stomach 
as  a  clinical  entity.  Pariser,^  Quintard,'  Mintz,*  and  others  have  re- 
ported cases. 

Undoubtedly,  not  in  every  case  in  which  bits  of  mucous  membrane 
are  washed  out  of  the  fasting  stomach  have  we  chronic  erosions.  I  have 
noted  in  several  cases  of  chronic  gastritis — in  which  unquestionably 
lavage  was  performed  in  an  unscientific  manner  by  the  physician  in 
attendance — the  appearance  of  these  small  fragments,  and  yet  the  patient 
never  subsequently  suffered  from  the  salient  symptoms  •  described. 
Traumatism  was  the  evident  cause. 

Erosions  may  occur  in  acute  cases.  I  was  recently  called  to  attend 
a  patient  with  acute  gastritis,  having  severe  and  persistent  vomiting 
streaked  with  blood,  and  though  I  washed  the  stomach  with  greatest 
care,  in  two  washings  several  pieces  of  gastric  mucous  membrane  were 
found,  evidently  exfoliation  from  the  acute  process  and  violent  vomiting. 
The  case  made  a  rapid  recovery  with  no  further  symptoms. 

Unrecognized  cases  of  chronic  erosions  occur,  but  those  recognized 
intravitam  by  the  clinical  symptoms  are,  so  far  reported,  comparatively 
few. 

Etiology. — Chronic  catarrhal  gastritis  is  the  chief  factor,  though 
Einhorn  reports  erosions  associated  with  hyperchlorhydria,  and  I  have 
seen  them  once  with  acid  gastritis,  and  once  with  achylia. 

Symptoms. — ^The  diagnostic  symptoms  described  by  Einhorn  are: 

Pain,  emaciation,  weakness  and  lassitude,  and  the  finding  in  the 
wash-water  after  lavage  of  one  or  more  small  pieces  of  gastric  mucous 
membrane.  There  is  usually  decrease  in  acidity  and  free  hydrochloric 
acid  and  considerable  mucus  (chronic  gastritis). 

Pains. — These  are  not  intense  and  occur  directly  after  meals,  ir- 
respective of  the  character  of  the  food.  They  last  one  or  two  hours 
and  are  never  severe.  There  are  usually  intervals  free  from  pain,  though 
rarely  the  pains  are  constant. 

Emaciation. — The  patients  lose  weight  at  first;  the  face  becomes 
rather  thin.  They  have  not  the  cachexia  of  cancer  nor  the  appearance  of 
suffering  as  in  ulcer. 

Weakness. — The  patient  feels  weak  and  unable  to  work,  and  likes 
keeping  quiet,  most  markedly  so  for  a  period  after  meals.  Loss  of  appe- 
tite is  present  in  some  cases. 

Pathology. — If  the  stomach  is  washed  out  in  the  fasting  condition, 
one  or  more  small  pieces  of  gastric  mucous  membrane  are  found  in  the 
wash-water.  They  appear  normal  under  the  microscope,  but  are  in- 
filtrated with  red  blood-cells.     This  lesion  is  constantly  found  after  lavage. 

^  N.  Y.  Med.  Rec,  June  23,  1894;  also  Jour.  Am.  Med.  Assoc,  May  20,    1894. 
'  Berlin,  klin.  Wochenschr.,  1900,  No.  43. 
'  Arch.  f.  Verdauungskrankheiten,  1901. 
*  Zeitschr.  f.  klin.  Med.,  Bd.  46,  1902. 


GASTRIC  EROSIONS  317 

Blood  is  rarely  present,  though  occasionally  the  wash-water  is  slightly 
streaked  with  it. 

Einhorn  believes  the  "erosions"  resulting  from  the  peeling  off  of 
the  mucous  membrane  are  responsible  for  the  pain  and  tenderness, 
and  that  it  has  not  yet  been  determined  whether  the  exfoliation  recurs  at 
the  same  place  after  healing,  or  in  new  regions  of  the  stomach. 

N.  W.  Jones'  describes  hemorrhagic  erosions  and  autopsy  findings 
in  chronic  erosions  (Einhorn's  disease).  Considerable  blood  was  found 
in  the  intestines,  and  blood  had  previously  been  found  in  the  stools. 
The  cause  of  death  is  not  given.  The  case  is  apparently  one  of  acute 
hemorrhagic  erosions,  recurrent  type,  or  possibly  more  the  aspects  of 
achlorhydria  haemorrhagica  gastrica,  and  not  of  chronic  erosions  at  all. 

Gastric  Analysis.— The  hydrochloric  acid  secretion  is,  as  a  rule,  de- 
creased and  also  the  total  acidity.  Considerable  mucus  is  usually  found. 
Rarely ;(  hyperchlorhydria  is  present,  and  in  one  case  I  found  acid  gastritis. 

In  washing  the  fasting  stomach,  one  to  four  pieces  of  mucous  mem- 
brane (0.3  to  0.4  cm.)  are  found.  They  are  blood-red,  and  under  the 
microscope  and  the  gastric  glands  and  red  corpuscles  are  visible. 

Prognosis. — The  disease  is  usually  of  long  duration,  with  at  times 
intervals  of  improvement. 

Treatment. — The  diet  depends  on  the  gastric  findings.  The  treat- 
ment is  the  same  as  for  chronic  gastritis,  acid  gastritis,  or  for  hyper- 
chlorhydria, depending  on  the  case.  Hydrotherapy  and  out-of-door 
exercise  are  of  service. 

If  deficient  hydrochloric  acid,  nux  vomica,  compound  tincture  of 
cinchona,  and  condurango  are  indicated;  if  hyperacidity,  the  alkalis, 
such  as  magnesia  usta  or  sodium  bicarbonate. 

There  are  three  methods  of  local  treatment: 

1.  Bismuth  Treatment. — Lavage  every  other  day  with  milk  of  magnesia 
to  dissolve  the  mucus,  and  t.i.d.  15  to  30  grains  (1.0-2.0)  of  bismuth 
subnitrate  before  meals. 

2.  Nitrate  of  Silver  Treatment. — This  is  superior  in  many  cases.  It 
may  be  administered  internally,  K  grain  (0.016)  in  solution  t.i.d.  three 
hours  after  eating;  lavage  with  an  alkali  every  two  or  three  days  de- 
pending on  the  mucus;  or  lavage  every  other  day  with  i  :  2000  to  i  :  1000 
silver  nitrate,  preceding  it  by  lavage  with  warm  water.  Argyrol  or 
protargol  i  :  2000  can  be  substituted. 

Einhorn  recommends  intragastric  galvanization  on  one  day,  with 
nitrate  of  silver  spray  preceded  by  lavage  on  the  following  day,  and 
so  alternating. 

He  first  washes  the  stomach  with  warm  water,  which  is  all  removed, 
and  then  sprays  the  stomach  with  his  instrument,  employing  10  c.c.  of  a 
0.1  to  0.2  per  cent,  solution  of  nitrate  of  silver  solution,  employing  most 
of  it  and  moving  the  tube  about.  The  bottle  should  be  opened  before 
removal  of  the  spray. 

3.  The  extract  of  the  suprarenal  gland  (Armour  &  Co.)  has  been 
recommended  by  Einhorn.     He  employs  it  in  his  powder-blower  and 

^  Jour.  Amer.  Med.  Assoc,  Oct.  14,  191 1. 


3l8  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

applies  it  every  other  day  to  the  stomach,  3  grains  (0.194)  at  a  time, 
instead  of  the  silver  nitrate  spray.     Good  reports  are  given  of  this  method. 

PERIGASTRITIS  AND  PERIGASTRIC  ADHESIONS 

Localized  perigastritis  with  the  formation  of  adhesions  to  other 
organs  may  result  from  various  causes,  among  which  are  the  follow- 
ing: gastric  ulcer;  recurrent  attacks  of  acute  gastritis  by  extension 
or  by  infection  from  within;  infections  from  the  gall-bladder,  liver, 
appendix,  spleen,  duodenum,  or  transverse  colon;  cancer  or  ulcer  of 
adjacent  organs;  and  tubercular  peritonitis.  Adhesions  are  more  fre- 
quently due  to  gastric  ulcer  and  are  not  at  all  uncommon  in  cases  in  which 
cicatrization  has  taken  place,  in  which  event  the  pylorus  and  lesser 
curvature  are  most  frequently  involved.  In  at  least  7  to  8  per  cent. 
of  cases  of  gastric  ulcer  such  adhesions  occur.  They  may  also  take  place 
to  the  parietal  peritoneum.  Infection  of  the  gall-bladder  is  a  quite 
frequent  cause  of  gastric  adhesions,  particularly  of  the  spider  web  variety, 
which  may  produce  pyloric  stenosis  with  dilatation  of  the  stomach,  and 
at  times  even  gastric  hemorrhage  from  the  congestion  caused  by  cir- 
culatory interference,  so  that  the  diagnosis  of  stenosing  gastric  ulcer  has 
been  made.  R.  T.  Morris  particularly  refers  to  this  type.  The  stomach, 
liver,  and  gall-bladder  may  be  bound  together  by  adhesions  originating 
from  either  gastric  ulcer  or  gall-bladder  infection.  When  the  adhesions 
result,  for  example,  from  gastric  ulcer,  there  is  at  first  a  localized  peritonitis 
(perigastritis)  with  increased  pain,  tenderness,  at  times  vomiting,  and  a 
moderate  temperature  in  the  cases  of  more  acute  type.  The  location  of 
the  pain  and  tenderness  depends  on  the  site  of  the  perigastritis.  In  the 
subacute  cases  there  may  be  few  clinical  symptoms,  possibly  an  in- 
crease in  gastralgia,  with  some  interference  in  the  motility  of  the  stomach, 
increased  pain  when  the  stomach  is  distended  with  food,  some  loss  of 
flesh  and  strength,  etc.  If  ulcer  be  the  cause,  the  gastric  findings  do  not 
alter.  Disturbances  of  gastric  secretion,  however,  frequently  occur 
with  gall-bladder  disease  (infection)  with  accompanying  adhesions. 
J.  A.  Lichty^  has  experimentally  demonstrated  on  dogs  disturbances  of 
the  gastric  functions  produced  by  gall-bladder  infection.  If  the  adhesions 
afifect  the  pylorus,  stenotic  dilatation  of  the  stomach  may  result  with  its 
accompanying  symptoms.  Gastroptosis  may  also  occur  from  adhesions 
forming  on  the  lower  border  of  the  stomach  and  dragging  down  the  organ. 
Adhesions  to  the  intestines  may  produce  acute  or  chronic  intestinal  ob- 
struction and  distention  of  the  gall-bladder  from  interference  with  the 
common  duct.  If  adhesions  involve  the  pancreas  affecting  the  duct, 
disturbance  of  the  pancreatic  functions  may  result. 

A  local  abscess  may  occasionally  occur  which  may  require  surgical 
intervention.  In  some  cases  one  can  palpate  a  thickened  mass  due  to 
the  perigastritis. 

If  the  perigastritis  and  adhesions  occur  at  the  cardia,  partial  sten- 
osis may  result,  with  regurgitation  of  food,  etc.,  the  symptoms  of  sten- 
osis of  the  esophagus. 

1  Amer.  Jour.  Med.  Sci.,  Jan.,  1911. 


PERIGASTRITIS  AND  PERIGASTRIC  ADHESIONS  319 

A  frequent  symptom  observed  is  that  when  adhesions  are  present 
in  the  stomach,  exclusive  of  the  cardia,  as  above  noted,  after  disten- 
tion of  the  stomach  with  food  or  gas,  considerable  pain  often  follows 
from  dragging  on  the  adhesions. 

Diagnosis. — The  previous  history  of  gastric  ulcer  or  some  other 
intra-abdominal  lesion  is  of  great  assistance  in  the  diagnosis.  Local 
tenderness  and  pain,  increased  pain  after  distention  of  the  stomach 
with  food,  the  symptoms  of  pyloric  stenosis  with  dilatation  of  the  stomach 
(when  such  conditions  are  present)  are  of  service.  Sometimes  a  thickened 
mass  can  be  palpated. 

The  .T-rays  are  a  valuable  aid,  showing  local  disturbance  in  the  motility 
of  the  stomach,  a  change  of  contour,  and  in  some  cases  an  abnormal 
position  of  the  organ.  The  reader  is  referred  to  the  X-ray  Diagnosis  of 
Stomach  and  Gall-bladder  Disease,  where,  for  example,  the  abnormal 
position  of  the  pylorus  when  adherent  to  the  gall-bladder  is  well  illustrated. 

Treatment. — Perigastric  adhesions  in  most  cases  require  opera- 
tive interference.  If  a  localized  abscess  is  present  with  the  perigastri- 
tis, it  should  be  opened  and  drained.  Mild  types  of  adhesions  may  go 
for  years  without  operation,  but  there  is  invariably  considerable  dis- 
comfort, and  frequently  disturbances  of  the  gastric  secretion  ultimately 
result,  as  well  as  disturbances  of  motility  of  the  organ.  The  nervous 
strain  on  the  patient  is  marked  and  invalidism  results.  The  author 
advocates  operation  by  preference  even  on  these  cases. 

Adhesions  producing  pyloric  stenosis  require  operative  procedure.  . 


CHAPTER  XIII 

CANCER    OF    THE    STOMACH     (CARCINOMA    VENTRICULI)— 

OTHER  TUMORS  OF  THE  STOMACH— APPARENT  TUMORS 

OF  THE  STOMACH— FOREIGN  BODIES  IN  THE 

STOMACH 

CANCER   OF   THE   STOMACH    (CARCINOMA  VENTRICULI) 

Frequency. — In  an  analysis  of  30,000  cases  of  cancer,  W.  H.  Welch, 
of  the  Johns  Hopkins  Hospital,  finds  the  stomach  involved  in  21.4  per 
cent.,  standing  next  in  frequency  to  uterine  cancer.  Osier  states  that  there 
were  150  cases  of  carcinoma  ventriculi  in  8464  patients  admitted  to  the 
hospital  wards.  Haberlin  gives  41  per  cent,  from  1877  to  1886  in  his 
statistics,  while  Brinton  places  it  at  about  25  per  cent.  Virchow  stated 
that  the  stomach  was  the  site  of  primary  carcinoma  in  34.9  per  cent,  of 
all  cases,  while  d'Espine  places  it  at  45  per  cent.  William  J.  Mayo^ 
holds  that  nearly  one-third  of  all  cancers  occur  in  the  stomach.  The 
Census  Bureau  reports  out  of  a  total  of  140,088  deaths  from  cancer, 
the  stomach  and  liver  combined  were  36.4  per  cent.,  and  the  female 
genitals  14.7  per  cent.  In  a  study  of  2268  autopsies  at  the  Philadelphia 
General  Hospital,^  the  total  number  of  cases  of  primary  cancer  were  121. 
Of  these,  45  were  of  the  stomach;  32  were  in  males,  13  in  females.  There 
were  13  cases  of  uterine  cancer.  Kiittner^  comments  on  the  prevalence 
of  cancer  in  southeastern  Germany.  Haberlin  demonstrated  that  gastric 
cancer  is  on  the  increase  in  Switzerland,  and  Joseph  D.  Bryant  shows  the 
same  in  the  United  States.  Its  frequency  seems  to  vary  in  different 
countries,  Griesinger  having  never  observed  it  in  Egypt.  Coley*  shows 
the  general  increase  of  cancer. 

Age. — Welch  finds  that  three-fourths  of  his  cases  occured  between 
the  ages  of  forty  and  seventy.  Smithies*  reports  16  cases  of  gastric 
cancer,  9  females  and  7  males  under  thirty-one  years  of  age,  the  youngest 
only  eighteen  years  old  and  the  general  average  28.7  years.  The  duration 
of  previous  gastric  trouble  was  four  months  in  the  shortest  and  fifteen 
years  in  the  longest,  the  average  time  being  4.2  years.  In  no  case  was 
there  achylia,  the  average  free  HCl  being  26.  He  found  cases  showing 
the  longest  free  HCl  were  in  association  with  large  cancerous  ulcers,  a 
significant  fact.     Osier  analyzes  150  cases  as  follows: 

Between  twenty  and  thirty  years,  6  cases;  from  thirty  to  forty,  17; 
forty  to  fifty,  38;  fifty  to  sixty,  49;  sixty  to  seventy,  36;  seventy  to  eighty,  4. 

^  Journal  A.  M.  A.,  Aug.  23,  1913. 

^  Cancer  of  the  Stomach,  A  Statistical  Study  (J.  A.  McGlinn),  Amer.  Jour.  Surg., 
Dec,  1909. 

'  Therapie  der  Gegenwart,  Berlin,  Jan.,  191 1,  No.  i. 

*  Surgery,  Gynecology,  and  Obstetrics,  June,  1910,  pp.  591-597. 

*  Sixty-fifth  Annual  Meeting  A.  M.  A.,  June  22,  1914,  in  Journal  A.  M.  A.,  Nov. 
22,  1914. 

320 


CANCER   OF  THE   STOMACH    (CARCINOMA  VENTRICULl)  32I 

Fifty-eight  per  cent,  occurred  between  forty  and  sixty,  the  youngest 
case  was  twenty-two.  Welch's  statistics  show  the  majority  of  cases 
between  forty  and  sixty.  The  maximum  liability  to  cancer  of  the  stom- 
ach is,  therefore,  between  the  ages  of  forty  and  sixty.  Two  cases  of 
congenital  carcinoma  have  been  reported  and  also  several  cases  under  the 
age  of  thirty,  as  just  referred  to. 

Sex. — Welch  finds  cancer  of  the  stomach  slightly  more  frequent 
among  men,  1233  men  to  981  women;  and  Osier,  in  150  cases,  126  males 
and  24  females.  Statistics  vary  somewhat  regarding  percentages,  but 
it  seems  to  preponderate  in  males. 

Race.— Among  150  cases  at  the  Johns  Hopkins  Hospital,  there  were 
131  among  the  whites  and  19  among  the  blacks.  The  ratio  of  colored 
patients  to  white,  however,  in  our  hospitals  is  small. 

Heredity. — Since  several  members  of  one  family  have  been  afflicted 
with  cancer,  many  are  inclined  to  believe  heredity  plays  a  part.  Delafield^ 
and  Prudden  hold  that,  "while  the  influence  of  heredity  is  difficult  to 
estimate,  there  are  a  few  well  authenticated  cases  of  the  remarkable 
prevalence  of  malignant  tumors  in  families  within  a  few  generations." 

The  statistics  of  Williams  showed  that  in  235  cases  of  carcinoma  of 
the  uterus  or  breast,  9  per  cent,  gave  a  history  of  carcinoma  in  the  father 
or  mother,  while  in  nearly  20  per  cent,  there  was  evidence  of  carcinoma 
in  the  family;  though  such  statistics  are  suggestive  and  indicate  that  an 
hereditary  predisposition  to  the  development  of  tumor  may  exist,  this 
does  not  account  for  the  immediate  excitement  of  the  growth  of  tumors, 
and  is,  as  Menestrier  has  urged,  but  one  of  the  examples  of  hereditary 
disposition  which  is  observed  in  many  forms  of  disease,  such  as  infections, 
cerebral  apoplexy,  etc. 

Williams  cites  the  fact  that  the  father,  brother,  and  two  sisters  of 
Napoleon  died  of  cancer  of  the  stomach,  to  which  he  himself  succumbed. 

William  S.  Bainbridge,^  who  has  extensively  investigated  the  ques- 
tion, believes  that  the  hereditary  acquirement  of  cancer  requires  much 
more  study  before  definite  conclusions  can  be  formulated,  and  in  this 
I  agree. 

Etiology^ — Traumatism  has  been  given  as  a  frequent  cause  of  cancer 
of  the  stomach,  but  Osier  reports  only  one  case  in  his  series.  Prob- 
ably attention  is  drawn  to  this  part  by  reason  of  the  injury,  and  the 
tumor  is  thus  recognized  more  early.  Coley^  has,  however,  recently 
reported  a  number  of  cases  in  his  own  experience,  and  in  that  of  foreign 
observers,  in  which  traumatism  would  seem  to  act  as  a  direct  causative 
agent,  both  of  carcinoma  and  sarcoma.  John  B.  Deaver*  refers  to  the 
influence  of  trauma,  citing  as  an  example  skin  carcinoma  caused  by 
continued  exposure  to  the  .r-ray.  Cider,  sour  wines,  mental  worry,  and 
nervous  strain  have  been  suggested  as  predisposing  causes,  but  they  have 
no  influence. 

As  the  muscular  fibers  of  the  cardia  and  pylorus,  undergo  frequent 
expansion  and  contraction,  and  are  subject  to  more  work  than  other 

^  Handbook  of  Pathologic  Anatomy  and  Histology. 
^Boston  Med.  and  Surg.  Jour.,  June  27,  1907. 
^  Annals  of  Surg.,  April  and  May,  igii. 
*  Amer.  Jour,  of  Surg.,  Aug.,  191 1. 
21 


322  DISEASES  OF  THE   STOMACH  AND  INTESTINES 

portions  of  the  stomach,  Brinton  believes  the  necessarily  increased 
nutrition  of  these  parts  may  favor  glandular  proliferation  and  be  pro- 
ductive of  a  neoplasm. 

Some  consider  chronic  inflammatory  disease  of  the  mucous  mem- 
brane of  the  stomach  to  be  a  predisposing  factor  in  the  production  of 
carcinoma,  notably  the  polypoid  form  of  chronic  gastritis  (Menes trier). 
As  a  rule,  carcinoma  develops  without  a  previous  history  of  long-stand- 
ing gastric  disturbance,  and  I  agree  with  Ewald  and  Einhorn  in  believing 
these  conditions  have  no  influence. 

The  gastritis  found  with  cancer  is  a  secondary  condition.  The  de- 
velopment of  cancer  on  an  ulcer  scar  has  been  clinically  demonstrated  by 
Hauser.  Haberlin  places  about  7  per  cent,  of  cases  as  occurring  in  this 
manner,  while  Moynihan  gives  60  per  cent.  Of  the  tissue  removed  from 
the  stomach  and  duodenum  in  the  Mayo  clinic  since  1905  approximately 
60  per  cent,  of  the  specimens  showing  cancer,  gave  more  or  less  pathological 
evidence  of  the  precedence  of  ulcer  in  the  same  area.  Smithies^  states 
that  out  of  566  cases  operated  and  demonstrated  as  cancer  0.65  per  cent. 
^ave  early  clinical  evidences  of  chronic  gastric  ulcer.  Wilson^  published 
a  paper  in  December,  1914,  reporting  on  445  gastric  carcinomas  examined 
in  the  Mayo  clinic  in  which  he  states  that  in  all  probability  very  few  cases 
of  gastric  cancer  exist  which  have  not  originated  at  the  site  of  a  previous 
ulcerative  lesion  of  the  mucosa.  Wilson  and  McDowell  also  report  on 
the  relationship  between  gastric  ulcer  and  cancer.  MacCarty  and 
Broders^  show  the  enormous  incidence  of  cases  showing  the  characteristics 
of  simple  ulcer  plus  the  presence  of  carcinoma  (microscopic)  and  that  the 
differential  diagnosis  can  only  be  made  by  the  microscope.  It  is  now  held 
that  about  71  per  cent.^  of  cases  develop  from  ulcer.  McCarthy^  demon- 
strates that  even  radiography  plus  the  history  and  clinical  symptoms  will 
not  differentiate  between  a  chronic  gastric  ulcer  and  early  malignancy. 
He  shows  by  pathological  examination,  that  cases  believed  to  be  non- 
malignant  were  determined  to  be  undergoing  malignant  degeneration. 
This  further  emphasizes  the  necessity  of  radical  operation  in  all  cases  of 
chronic  gastric  ulcer. 

When  one  remembers  that  in  about  5  per  cent,  of  persons  dying  from 
all  causes  Brinton  finds  evidences  of  gastric  ulcer,  it  can  be  readily  under- 
stood how  carcinoma  can  develop  on  an  ulcer  scar  with  no  apparent  previous 
gastric  symptoms.  The  author's  view  is  that  70  per  cent,  develop  on 
a  previous  ulcer  in  spite  of  the  fact  that  Fenwick  reports  only  3  per 
cent,  of  cases  with  previous  ulcer  history,  and  Osier  2.6  per  cent.  These 
last  statistics  do  not  militate  against  the  theory  of  development  of 
carcinoma  on  the  base  of  an  occult  ulcer  with  no  symptoms.  Bloodgood," 
in  a  series  of  182  cases  from  the  Pathological  Laboratory  of  the  Johns 
Hopkins  Hospital,  notes  duration  of  disease  (symptoms)  in  67  cases,  ex- 

^  Journal  A.  M.  A.,  Nov.  15,  1913. 

*  Wilson  and  McDowell,  Amer.  Jour.  Med.  ScL,  Dec,  1914;  also  Mayo  clinic, 
vol.  vi,  1 9 14. 

'Arch.  Int.  Med.,  Feb.,  1914,  p.  208. 

*  Wilson  and  MacCarty,  Amer.  Jour.  Med.  Sci.,  Dec,  1909. 
'Amer.  Jour.  Med.  Sci,.  April  15,  1915. 

•Jour.  A.  M.  A.,  June  18,  1915. 


CANCER  OF  THE   STOMACH    (CARCINOMA  VENTRICULl)  323 

tending  over  a  period  of  two  to  six  years,  or  more.  This  suggests  to  the 
author  a  previous  ulcer. 

The  author  has  had  impressed  upon  him  by  two  practical  experiences, 
the  danger  of  non-radical  operation  in  chronic  gastric  ulcer,  both  in  private 
patients. 

In  the  first  case,  a  woman  aged  forty-five  with  chronic  gastric  ulcer  near 
the  pyloric  ring,  though  I  advised  resection  of  the  stomach,  the  operator, 
through  error  of  judgment,  would  only  consent  to  a  gastro-enterostomy. 
There  was  marked  improvement,  in  fact  for  one  and  one-half  years  an 
apparent  cure.  Gastric  symptoms  then  recurred  and  two  years  after 
the  first  operation,  the  patient  was  reoperated  for  cancer  which  had 
developed  at  the  site  of  the  old  ulcer,  and  died  directly  after  operation. 

The  second  patient,  a  woman  of  fifty-seven  was  anemic,  had  lost  some 
weight;  achlorhydria  was  present,  but  no  Boas-Oppler  bacilli.  The  radio- 
graphs showed  hypermotility  of  the  stomach,  but  no  deformity  was  visible. 
I  believed  a  superficial  ulcer  or  erosion  to  be  present,  insufficient  as  yet 
to  cause  deformity.  Having  radical  views  I  advised  exploration.  She 
preferred  medical  treatment.  It  seemed  absolutely  impossible  to  improve 
her  nutrition,  there  only  being  a  few  pounds  gain  under  forced  feeding. 
Her  pain  would  disappear  and  then  recur.  About  six  months  later  radio- 
graphs were  again  taken,  showing  hypermotility  of  the  stomach  with 
slight  deformity  near  the  pylorus,  in  my  belief  a  chronic  ulcer  with  prob- 
ably commencing  cancerous  degeneration.  Operation  was  once  more  ad- 
vised. The  patient  then  drifted  into  other  hands,  but  I  learned  that  she 
died  about  six  months  later  from  gastric  cancer. 

In  securing  the  history  from  patients  with  gastric  cancer,  there  is  a 
tendency  to  center  the  attention  on  the  existing  symptoms,  or  on  those 
that  have  been  marked  for  a  recent  period.  Usually,  however,  with  per- 
sistent questioning  one  can  secure  a  history  of  some  previous  gastric  dis- 
turbance frequently  dating  back  a  considerable  period.  In  a  series  of 
20  cases  of  cancer,  the  writer  finds  that  75  per  cent,  of  cases  gave  a  his- 
tory of  previous  gastric  disturbances  before  their  present  illness,  while 
five  of  these  cases  gave  an  undoubted  ulcer  history.  These  figures 
are  of  course  small  as  compared  with  hospital  records,  but  they  are 
suggestive. 

Some  hold  that  cancer  originates  from  embryonic  rests,  or  prenatal 
wrongly  placed  tissue  elements,  which  at  some  time  take  on  a  morbid 
action  and  develop  into  cancer,  others  that  local  injury  or  irritation  may 
be  the  dominant  factor  in  determining  the  activity  of  these  misplaced 
cells.  Duncan  Bulkley^  notes  the  rarity  of  cancer  in  vegetarian  people 
such  as  in  Japan,  China,  etc.,  and  its  frequency  among  the  meat  eating 
races^  believing  this  may  have  some  bearing  in  activating  the  process. 
Ross^  holds  there  is  a  failure  in  the  potash  element  in  patients  who  are 
subject  to  cancer,  while  Lane  believes  that  the  left  breast  for  example  be- 
comes indurated  as  a  result  of  autointoxication  (intestinal  toxemia)  and 
cancer  may  result.     Cancer  of  intestines,  etc.,  may  also  occur. 

Regarding  the  parasitic  origin  of  cancer  and  its  infectious  nature 

1  Med.  Rec,  Oct.  24,  1914. 

'  Cancer,  the  Problem  of  Its  Genesis  and  Treatment,  London,  191 2. 


324  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

there  is  much  dispute.  Scheurlein  beHeved  he  had  discovered  a  bacillus, 
but  later  researches  demonstrated  his  error. 

Gaylord,  Park,  and  Adami  hold  to  the  parasitic  theory,  and  Gaylord 
states  that  in  all  the  organs,  including  the  blood  taken  from  cases  dying 
of  cancer,  certain  organisms  (parasites)  are  found.  He  has  inoculated 
guinea-pigs  and  dogs  with  peritoneal  fluid  from  a  human  abdominal 
tumor  and  produced  adenocarcinoma  in  the  lung  and  liver.  Coley  has 
secured,  in  a  few  cases,  good  results  in  the  treatment  of  cases  chiefly  of 
sarcomata  and  of  a  few  cases  of  carcinoma  by  the  injection  of  his  serum, 
and  I  have  personally  seen  a  favorable  result  in  one  case  of  kidney  sarcoma. 

Psorosperms  have  been  found  in  cancer  cells,  but  it  has  not  yet  been 
proved  whether  they  are  real  psorosperms  or  dried-up  and  changed 
cells.  Beard's  recent  theory  and  his  suggestion  of  the  use  of  trypsin  in 
the  treatment  of  cancer  has  been  proved  of  no  value.  We  must  confess 
so  far  the  origin  of  cancer  has  not  yet  been  determined,  though  I  believe 
it  will  eventually  be  demonstrated  to  be  due  to  some  bacillus  or  parasite 
in  spite  of  many  views  to  the  contrary. 

Morbid  Anatomy. — Waldeyer  demonstrated  that  cancer  of  the 
stomach  originated  from  the  glandular  structure  of  the  mucous  mem- 
brane, being  an  atypic  proliferation  of  the  epithelium  of  the  glands. 
Beginning  in  the  mucosa,  it  infiltrates  the  submucosa,  the  muscular  coat, 
and  extends  to  the  serosa.  Early  in  the  development  of  the  disease  the 
lymphatic  glands  become  enlarged,  particularly  those  of  the  lesser  curva- 
ture. Metastatic  growths  may  take  place.  The  cancerous  growth, 
especially  of  a  certain  type,  may  slough  and  form  irregular  ulcers. 

Varieties. — The  most  common  varieties  of  cancer  are  the  cylindric- 
celled  adenocarcinoma  (or  epithelioma)  and  the  encephaloid  or  medullary 
carcinoma;  next  in  frequency  is  the  scirrhus,  and  least  frequent,  the 
colloid  cancer. 

1.  Adenocarcinoma  (Cylindric-celled)  or  Epithelioma. — This  type  forms 
soft  tumors,  of  firmer  consistency  than  the  medullary  type,  and  sloughing 
more  slowly.  Microscopically,  the  section  shows  elongated  tubular 
spaces  filled  with  columnar  epithelium,  and  the  intervening  stroma  is 
abundant.  Gradually  the  tubular  spaces  develop  into  cell-nests.  There 
is  frequently  infiltration  of  the  connective  tissue  with  white  blood- 
corpuscles.  Cystic  degeneration  is  quite  common.  Metastases  and 
hemorrhage  may  occur. 

2.  Medullary  Carcinoma. — This  occurs  in  soft,  spongy,  fungating 
masses,  which  involve  all  the  coats  of  the  stomach  and  usually  ulcerate 
early.  It  is  large  and  often  flat,  projecting  above  the  mucous  membrane, 
and  may  form  villous-like  projections,  or  a  cauliflower-like  outgrowth. 
It  is  soft  and  grayish  or  yellowish  white  and  contains  many  blood-vessels 
and  cells.  Microscopically,  it  shows  scanty  stroma,  enclosing  alveoli 
containing  irregular  polyhedral  and  cylindric  cells.  It  is  often  blackish 
in  color,  due  to  hemorrhage  (melanotic),  and  has  a  tendency  to  ulcerate. 
Metastases  are  frequent. 

3.  Scirrhous  {Fibrous)  Carcinoma. — This  is  characterized  by  great 
hardness,  due  to  abundance  of  stroma  and  the  limited  amount  of  alveolar 
structure.     The  large  amount  of  connective  tissue  makes  the  tumor  very 


CANCER    OF   THE   STOMACH    (CARCINOMA  VENTRICULl)  325 


• 


firm  and  compact.  It  cuts  almost  like  cartilage,  and  on  section  has  a 
yellow  or  grayish-white  appearance.  There  is  little  tendency  to  ulcerate, 
except  at  a  late  stage  superficially,  and  secondary  metastases  are  not 
common.  It  is  seen  quite  frequently  at  the  pylorus,  there  being  a  diffuse 
thickening  and  hardening  of  the  wall  and  then  a  contraction,  being  a 
common  cause  of  stenosis.  The  tumor  may  be  diffuse,  involving  all  parts 
of  the  stomach,  when  it  may  be  difficult  to  recognize  it  microscopically 
from  cirrhosis  ventriculi.  It  has  occurred  in  the  stomach  secondary  to 
ovarian  cancer,  and  as  a  part  of  a  diffuse  carcinomatosis,  with  involve- 
ment of  the  small  and  large  intestines.  It  may  be  combined  with  the 
medullary  form. 

4.  Colloid  Carcinoma. — This  type  of  cancer  is  peculiar,  from  the  fact 
that  it  invades  widely  all  the  coats  of  the  stomach.  It  spreads  with  great 
frequency  to  the  neighboring  parts,  and  at  times  causes  secondary  growths 
of  the  same  nature  in  other  organs. 

The  appearance  on  section  is  distinctive,  showing  large  alveoli  filled 
with  translucent  gelatinous  colloid  material.  This  is  often  present,  even 
to  the  naked  eye.  On  scraping,  no  cancer  juice  exudes,  but  gelatinous 
fragments. 

Various  transitional  forms,  from  one  variety  to  another,  are  often 
found.  Rarely  a  carcinoma  consisting  of  squamous  epithelium  may 
extend  from  the  esophagus  into  the  cardia. 

Brinton,  in  analyzing  i8o  cases  of  cancer,  finds  the  scirrhus  type  to 
be  most  common  (72  per  cent.),  the  medullary  next  in  frequency,  though 
other  observers,  notably  Osier,  consider  the  epithelioma  to  be  most 
frequent. 

Cancer  of  the  stomach  is  usually  primary,  though  secondary  growths 
have  been  reported. 

Cancer  may  also  extend  from  the  liver,  pancreas,  and  intestines. 

Types  of  Growth. — Medullary  and  colloid  cancers  involve  large  areas 
of  mucous  membrane,  growing  little  above  the  surface,  being  somewhat 
flattened,  with  occasional  rough  nodular  masses.  Blood  extravasations 
and  adhesions  to  neighboring  organs  are  of  frequent  occurrence. 

The  scirrhus  variety  extends  usually  only  over  a  small  portion  of  the 
mucosa,  and  may  develop  extensively  in  thickness,  growing  in  depth  and 
height.  The  latter  type,  however,  occasionally  infiltrates  the  entire 
stomach,  causing  a  contraction  of  the  organ  (cancer  atrophicans). 

Secondary  Changes  in  the  Mucous  Membrane  of  the  Stomach. — 
Hammerschlag  has  investigated  the  gastric  mucosa  in  cases  of  carcinoma 
by  examining  fresh  pieces  of  mucous  membrane  removed  in  cases  of 
resection  of  the  pylorus  at  the  time  of  gastro-enterostomy,  examining  also 
the  section  of  the  stomach. 

When  the  hydrochloric  acid  secretion  was  intact,  there  were  no  changes 
in  the  mucous  membrane.  When  it  was  absent  and  lactic  acid  present, 
changes  occurred,  and  there  were  found  destruction  of  the  rennet  glands 
in  certain  areas  and  small-celled  infiltration  and  formation  of  connective 
tissue  in  the  gastric  mucosa,  also  mucoid  changes  or  cystic  degeneration; 
in  effect,  a  secondary  atrophic  gastritis.  Eosinophile  cells  are  present. 
Hypertrophy  of  the  muscular  fibers  and  connective  tissue  has  been  ob- 


326  DISEASES   OF   THE   STOMACH   AND  INTESTINES 


• 


served.  Ewald  has  also  noted  that  the  entire  mucosa  may  show  the 
lesions  of  chronic  gastritis.  It  is  interesting  to  learn  that  Fenwick  has 
demonstrated  that  atrophic  gastritis  may  occur  with  carcinoma  of  the 
breast  and  uterus.  Wilson  and  MacCarty,  however,  in  an  extensive  study 
of  230  stomachs  resected  by  William  Mayo  for  carcinoma  of  the  stomach, 
in  the  majority  of  which  free  hydrochloric  acid  was  absent,  found  that  in 
none  of  them  was  there  a  general  atrophy  of  the  mucous  membrane.  There 
was  present,  almost  without  exception,  a  marked  proliferation  of  the 
mucous  membrane  at  the  margin  of  the  ulcer,  but  usually  an  accompanying 
round-cell  infiltration  of  the  submucosa  of  a  greater  or  less  degree. 

Location  of  the  Cancer. — The  development  of  the  cancer  may  take 
place  in  various  regions  of  the  stomach,  at  the  pylorus,  or  cardia,  or  within 
the  organ,  causing  variation  in  the  symptoms  according  to  location,  and 
in  each  case  necessitating  a  special  plan  of  treatment. 

Welch's  analysis  of  1300  cases  is  as  follows:  Pyloric  region,  791; 
lesser  curvature,  148;  cardia,  104;  posterior  wall,  68;  the  whole  or  greater 
part  of  the  stomach,  61;  multiple  tumors,  45;  greater  curvature,  34; 
anterior  wall,  38;  fundus,  19. 

In  Brinton's  cases,  60  per  cent,  were  found  at  the  pylorus.  The 
latter  is  evidently  the  point  of  selection. 

Wm.  J.  Mayo  believes  70  per  cent,  involve  the  pyloric  region,  and  that 
60  per  cent,  originate  in  the  pylorus  or  within  3  inches  of  it. 

Changes  in  the  Shape  of  the  Stomach. — If  the  cancer  is  situated  at 
the  cardia,  the  stomach  is  usually  retracted  and  small  in  size,  while  the 
esophagus  above  the  stricture  is  dilated.  If  the  tumor  constricts  the 
pylorus,  the  stomach  will  be  dilated.  Gastroptosis  of  varying  degree 
may  be  present  by  reason  of  the  weight  of  the  tumor  dragging  down  the 
pylorus,  and  it  may  even  lie  down  in  the  pelvis.  Adhesions  may  distort 
the  shape  of  the  organ,  and  Riegel  reports  an  hour-glass  contraction  of 
the  stomach,  resulting  from  cancer. 

Perforation. — Perforations  into  other  viscera,  through  the  skin,  or 
into  the  general  peritoneal  cavity  are  rare.  The  aorta  has  been  perfor- 
ated. Subphrenic  abscess  has  been  produced.  Perforation,  however, 
seldom  occurs. 

Cancerous  Metastases. — In  an  analysis  of  1574  cases  by  Welch, 
metastases  occurred  in  the  lymphatic  glands  in  551;  in  the  liver,  475;  in 
the  peritoneum,  omentum,  and  intestines,  357;  in  the  pancreas,  122;  in 
the  pleura  and  lung,  98;  in  the  spleen,  26;  in  the  brain  and  meninges,  6; 
in  other  parts,  92. 

Some  interesting  material  has  been  furnished  by  Eisner^  regarding 
cancerous  metastases  of  the  nervous  system  from  cancer  of  the  stomach  or 
intestines.  He  describes  peripheral  invasion  with  symptoms  of  multiple 
neuritis.  KlippeP  reports  five  cases  of  this  type.  Schlesinger^  gives 
statistics  as  to  spinal  invasion.  Eisner  reports  three  cases,  in  one  of  which 
spinal  symptoms  preceded  the  gastric  symptoms,  and  in  another  case  the 
spinal  symptoms  were  so  severe  that  they  masked  the  presence  of  the 

^  N.  Y.  Med.  Jour.,  Jan.  21,  191 1. 

2Thfese,  Paris,  1889. 

^  Beitrage  zur  Klinik  des  Ruckenmarks  und  Wirheltumoren,  Jena,  1889. 


CANCER   OF  THE   STOMACH    (CARCINOMA  VENTRICULl)  327 

♦ 
primary  stomach  growth.  The  bodies  of  the  vertebrae  were  first  involved. 
These  spinal  cases  are  characterized  by  "agonizing  pain."  Pinatelle  and 
Cavaillon^  describe  two  cases  of  gastric  cancer  with  secondary  deposits  in 
the  cranial  bones  and  meninges,  and  Holden^  reports  a  case  of  invasion 
of  the  optic  nerve  secondary  to  gastric  carcinoma. 

The  abdominal  lymph-glands  are  usually  affected,  but  the  cervical 
and  inguinal  glands  are  sometimes  attacked. 

Secondary  growths  may  occur  at  the  navel,  or  in  the  skin  in  the  im- 
mediate vicinity.  Infection  occurs  either  by  the  blood-vessels  or  lymph- 
channels.     Direct  invasion  by  continuity  may  take  place. 

The  medullary  and  colloid  types  of  carcinoma  are  often  associated  with 
metastases.  Sometimes  numerous  small  cancerous  deposits  occur  in  the 
pleura.  The  "microscope  will  differentiate  them  from  tuberculosis,  though 
they  have  occurred  together.  Rarely,  metastases  are  found  in  the  eyes, 
as  noted  above. 

Symptoms. — There  are  general  symptoms  and  special  symptoms, 
depending  on  the  location  of  the  growth. 

General  Symptoms. — Usually  a  patient  of  middle  age,  fifty  to  sixty 
years,  up  to  a  short  time  previous — a  few  months  or  so — being  in  perfect 
health  and  having  had  no  gastric  symptoms,  will  begin  to  complain  of 
slight  dyspeptic  disturbance,  loss  of  appetite,  and  fulness,  pressure,  and 
discomfort  after  eating.  The  author  believes  that  this  statement  must 
be  modified,  in  view  of  the  fact  that  a  careftd  history  will  usually  eUcit  some 
previous  gastric  disturbance  or  exacerbation,  though  at  times  slight  at  first, 
or  a  previous  so-called  dyspepsia,  Moynihan's  and  Rodman's  views  are 
noted  below.  Undoubtedly  a  history  of  former  gastric  ulcer,  in  some  cases 
years  before,  can  often  be  obtained.  Kuttner'^  reports  that  30  per  cent, 
of  his  cancer  patients  had  suffered  for  years  from  stomach  trouble.  Belch- 
ing occurs,  also  more  or  less  loss  of  sleep  and  loss  of  strength — the  symptoms 
looking  much  like  a  mild  gastritis.  The  tongue  is  usually  thickly  coated. 
The  symptoms  gradually  become  more  marked.  Rarely  the  attack  be- 
gins more  acutely.  The  feeling  of  discomfort  gradually  merges  into  pain. 
This  is  generally  not  of  the  severe  spasmodic  type  of  ulcer,  but  is  con- 
tinuous in  character,  there  not  being  the  intermissions  of  freedom  as  in 
ulcer.  It  may  remit  somewhat.  The  pain  is  at  times  increased  by  the 
food,  but  is  often  intense  at  a  later  period  after  eating  than  in  ulcer.  With 
the  belching  there  is  at  first  regurgitation  of  food,  later  vomiting,  usually 
not  after  every  meal,  but  once  or  twice  a  day.  This  is  a  prominent 
symptom  when  the  growth  causes  a  stenosis  of  the  pylorus. 

I  have  had  a  patient  with  carcinoma  of  the  greater  curvature  and 
body  of  the  stomach,  an  inoperable  case  who  has  never  vomited  at  all, 
the  motor  function  being  fairly  good. 

Later,  hematemesis  occurs,  generally  several  times  in  succession,  and 
the  vomitus  is  of  coffee-ground  appearance  and  not  large  in  quantity. 
The  tumor  usually  becomes  palpable  at  this  time,  though  often  earlier. 
The  patient  has,  meanwhile,  been  steadily  losing  weight,  and  this  loss 

^  Progres  Medical,  April  14,  1906. 

*  Arch,  of  Ophthalmol.,  1902,  xxi,  pp.  427-432. 

2  Therapie  der  Gegenwart,  Berlin,  Jan.,  1911,  p.  411,  No.  i. 


328  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

becomes  more  and  more  marked  and  anemia  and  cachexia  are  prominent. 
He  becomes  more  weak  and  prostrated  and  finally  dies  of  inanition  or 
of  complications.  These  constitute  the  symptoms  of  a  straightforward 
case.  Unfortunately  cases  of  apparently  simple  chronic  ulcer  of  the 
stomach  with  the  symptoms,  gastric  analyses,  and  radiological  findings  of 
ulcer  have  proved  to  be  incipient  carcinoma.  In  this  connection  Smithies^ 
makes  the  following  interesting  statement:  "The  early  diagnosis  of  gastric 
cancer  is  a  microscopic  one,  it  is  possible  from  histologic  study  of  freshly 
removed  tisstte;  such  tissue  is  seen  least  developed  in  those  patients  whose 
gastric  history  has  been  that  of  chronic  recurring  peptic  idcer  and  in  whom 
to  eye  and  hand  such  ulcer  appears  at  laparotomy. ^^  From  the  study  of  921 
cases  of  gastric  cancer  he  groups  the  following  classes  of  cases: 

1.  Gastric  cancer  coming  to  laparotomy  for  clinically  benign  ulcer  and 
in  whom  cancer  was  diagnosed  microscopically. 

2.  Gastric  cancer  clinically  developing  in  patients  with  years  of  ante- 
cedent dyspepsia  of  the  ^^ peptic  ulcer  type^'  in  whom  malignancy  subse- 
quently appeared. 

3.  Gastric  cancer  in  those  who  previous  to  the  onset  of  this  disease  had 
enjoyed  perfect  gastric  health. 

4.  Gastric  cancer  in  patients  in  whom  malignancy  followed  periods  of 
gastric  disturbance  of  no  clinical  type. 

5.  Gastric  cancer  in  individuals  who  presented  few  clinical  evidences 
of  a  malignant  process  primary  in  the  stomach  wall. 

6.  Gastric  cancer  secondary  to  an  extragastric  malignant  process. 
Bleeding,  constant  nausea,  distention,  diarrhea,  persistent  pain,  loss 

of  appetite,  weight  and  strength,  and  vomiting  may  usher  in  the  malignant 
stage. 

Various  types  of  symptoms  may  therefore  occur  and  yet  the  case  be 
malignant. 

The  author  of  this  volume  has  long  held  that  chronic  gastric  ulcer 
should  be  considered  a  precancerous  condition  and  should  receive  the 
surgical  treatment  of  cancer. 

Rodman^  reports  that  within  a  year  he  has  seen  5  cases  in  which  it  was 
practically  certain  that  carcinoma  of  the  stomach  was  preceded  by  a  long- 
standing ulcer,  in  one  instance  for  twenty-seven  years,  in  another,  nearly 
twenty  years.  Moynihan^  states  that  in  his  last  22  cases  of  carcinoma  of 
the  stomach  operated  upon,  16  patients  gave  a  previous  history  of  gastric 
ulcer.  In  2  cases  a  history  of  chronic  indigestion,  extending  for  over 
'twenty-five  years,  was  given.  Hence,  in  72.1  per  cent,  there  had  been  a 
gastric  ulcer  years  before.  The  shortest  interval  between  the  attack  of 
gastric  ulcer  and  the  onset  of  the  symptoms  leading  to  operation  was 
three  years,  the  longest  interval  twenty-six  years,  while  2  patients  gave 
a  history  of  less  than  three  months.  In  the  same"  article  Moynihan  reports 
17  additional  cases  of  carcinoma  upon  which  he  operated,  out  of  which 
8  gave  a  previous  history  of  gastric  ulcer.  These  records  show  that  a 
careful  anamnesis  will  usually  elicit  previous  gastric  disturbances. 

^  Cancer  of  the  Stomach  (Smithies  and  Ochsner),  W.  B.  Saunders  Co.,  1916. 
^  Jour.  Amer.  Med.  Assoc,  Jan.  18,  1908,  pp.  165-169. 
*  Brit.  Med.  Jour.,  Feb.  17,  1906,  p.  370. 


CANCER    OF   THE    STOMACH    (CARCINOMA  VENTRICULl)  329 

The  general  symptoms  are  modified  by  the  position  of  the  growth. 
A  brief  analysis  of  the  symptoms  is  advisable. 

Anorexia,  or  loss  of  appetite,  occurs  in  about  85  per  cent,  of  the  cases, 
and  it  seems,  as  a  rule,  to  be  progressive.  There  is  at  times  a  special 
aversion  to  meat.  Riegel  believes  that  in  the  early  stages,  while  the 
motor  power  remains  undisturbed,  the  appetite  remains  good.  This 
would  seem  as  if  toxemia  were  a  factor.  Boas  reports  fair  or  increased 
appetite  in  some  cases,  believing  loss  of  appetite  to  be  due  to  lack  of  care 
of  the  mouth  and  tongue.  The  toxemic  theory  of  loss  of  appetite  seems 
most  logical. 

Pain. — Pain  is  the  most  constant  symptom,  Osier  reporting  it  in  130 
out  of  150  cases;  Brinton  finds  it  in  92  per  cent,  of  his  patients,  and  others 
report  a  higher  percentage.  It  usually  begins  at  an  early  date,  generally  in 
the  epigastrium,  but  may  be  referred  to  the  hypochondriac  regions,  the 
sternum,  or  sometimes  extends  to  the  shoulders  or  back.  It  may  be  lanci- 
nating, or  of  a  dull,  gnawing,  or  burning  character.  There  may  be  ten- 
derness on  pressure  in  the  epigastrium.  The  pain  does  not  occur  in 
paroxysms  and  is  not  relieved  by  vomiting,  as  in  ulcer.  It  is  continuous 
and  never  entirely  disappears,  though  it  may  remit.  As  a  rule,  it  is  less 
intense  than  with  ulcer.  It  is  not  relieved  at  the  end  of  gastric  digestion. 
In  some  cases  it  may  occur  more  markedly  after  eating,  though  it  is  not 
especially  influenced  thereby.  In  other  cases  there  may  be  more  of  a 
painful  dull  feeling,  and  it  is  not  circumscribed  as  in  ulcer.  Sometimes 
over  the  region  of  the  tumor  the  pain  is  most  intense,  as  is  the  tenderness. 
Head  believes  there  are  areas  of  skin  tenderness  between  the  nipple  and 
umbilicus  in  front  and  the  fifth  to  the  twelfth  dorsal  vertebrae  behind. 
Exacerbations  of  pain  are  caused  by  ulceration  of  the  growths,  or  by 
formation  of  adhesions. 

Moreover,  Erlanger^  describes  cases  in  which  attacks  of  pain  diag- 
nosed in  some  cases  as  intercostal  neuralgia  were  the  first  or  the  principal 
sign  of  gastric  cancer.  The  pain  radiated  to  the  shoulder  in  one  case. 
One  must  think  of  the  possibility  that  neuralgic  pains  may  be  due  to  the 
cancerous  involvement  of  the  regions  innervated  by  the  intercostal,  lumbar, 
or  sacral  nerves. 

Vomiting. — It  may  come  on  early,  but  more  usually  later.  Osier 
reports  it  in  128  cases  out  of  150;  and  Brinton  in  87  per  cent.  At  first 
it  occurs  at  rather  long  intervals,  but  later  may  be  present  several  times 
a  day.  It  is  more  frequent  when  the  pylorus  is  involved,  and  may  come  on 
some  hours  after  the  ingestion  of  food,  or  at  times  on  rising,  when  there 
may  be  mucus  or  undigested  food  in  the  vomitus.  It  may  be  offensive  in 
odor  or  contain  changed  blood,  microorganisms  CBoas-Oppler  bacilli), 
and  isolated  yeast-cells;  but  rarely  sarcinae,  which  are  most  common  in 
benign  stenosis.  Vomiting  can  occur,  even  if  the  orifices  are  not  in- 
volved; if  the  cardia  is  affected,  then  regurgitation  is  characteristic. 

Extensive  involvement  of  the  anterior  or  posterior  wall  or  fundus 
may  be  present  without  vomiting. 

Hemorrhage  occurred  in  36  of  Osier's  cases  out  of  150;  while  Brinton 
places  it  at  42  per  cent.  Riegel  believes  these  percentages  too  low, 
^  .\rchiv  fiir  Verdauungs-Krankheiten,  Berlin,  82. 


33©  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

as  hemorrhage  may  be  occult,  or  often  not  examined  for  in  the  vomitus 
or  stool.  The  blood  is  occasionally  ejected  in  sufficient  quantity  to  be 
visible.  It  is  more  frequently  mixed  with  gastric  juice,  food,  and  mucus, 
and  presents  a  blackish,  brownish,  or  coflFee-ground  appearance;  is  rarely 
bright  red,  Osier  finding  it  in  three  cases.  The  quantity  is  much  less  than 
with  ulcer,  though  frequent  small  hemorrhages  may  occur.  Blood  in 
the  stool  (melena)  may  accompany  it,  though  this  is  rarer  than  in  ulcer. 
A  fatal  hemorrhage  seldom  occurs. 

Loss  of  Weight  and  Cachexia. — Progressive  emaciation,  especially 
if  the  disease  is  running  a  rapid  course  or  has  existed  for  some  time, 
is  a  consistent  feature.  In  the  early  stages  we  may  occasionally  see 
patients  who  appear  fairly  healthy  or  have  little  loss  of  weight,  or  at 
times  temporary  improvement  may  occur  under  treatment.  Unfor- 
tunately, this  is  evanescent,  and  progressive  emaciation  takes  place. 
In  the  later  stages  this  is  marked,  as  are  the  sallow  skin  and  peculiar 
ashy  and  cachectic  appearance,  with  loss  of  strength  proportionate  to  the 
loss  of  weight. 

The  Blood. — Anemia  is  always  present,  and  usually  marked  and 
progressive;  when  pyloric  stenosis  occurs  with  dilatation  and  insuffi- 
cient water  absorption,  on  account  of  the  concentration  of  the  blood 
the  number  of  red  cells  may  not  be  greatly  reduced. 

The  average  count  in  59  of  Osier's  cases  was  3,712,186  per  cubic 
millimeter.     Average  of  the  hemoglobin  was  44.9  per  cent. 

Schneyer^  has  shown  that  normal  digestive  leukocytosis  is  absent 
in  gastric  cancer,  and  that  the  number  of  leukocytes  during  digestion 
and  fasting  is  the  same.  Osier  claims  that  only  54  per  cent,  gave  positive 
reaction. 

Leukocytosis  is  present  in  gastric  carcinoma,  usually  of  mild  de- 
gree, and  rarely  above  12,000  to  15,000.  Eosinophilia  is  usually  pres- 
ent and  suggestive.  We  find  some  cases  without  apparent  tumor  in 
which  the  blood  count  is  so  low  as  to  be  suggestive  of  pernicious  anemia, 
but  the  absence  of  megaloblasts  and  the  presence  of  leukocytosis  speak 
for  cancer. 

Tumor. — In  connection  with  the  symptoms,  the  presence  of  a  tumor 
in  the  gastric  region  is  a  reliable  diagnostic  point.  In  the  early  stage 
it  often  cannot  be  determined.  If  large  and  superficial,  it  is  readily 
detected.  In  Osier's  150  cases,  tumor  was  detectable  in  115.  The 
methods  of  its  determination  are  as  follows: 

1.  Inspection. — Position  should  be  dorsal  and  the  knees  flexed  to 
relax  the  abdomen.  In  some  cases  a  protrusion  can  be  seen  in  the  gastric 
region  below  the  ensiform,  or  at  the  margin  of  the  ribs.  If  there  is  dilata- 
tion, the  lower  curvature  of  the  stomach  may  appear  as  an  arched  line 
below  the  umbilicus,  moving  up  and  down  during  respiration.  Peris- 
taltic movements  are  present  with  stenosis.  With  gastroptosis,  the 
lesser  curvature  may  be  seen  at  times  and  the  tumor  situated  thereon 
moving  during  respiration.  If  the  tumor  is  at  the  pylorus,  it  may  draw 
the  stomach  downward  and  the  protrusion  may  be  seen  low  down  in  the 
abdomen,  or  even  at  the  pelvic  brim.  Pulsation  from  the  aorta  may  be 
^Berliner  klin.  Wochenschr.,  1894,  No.  41. 


CANCER   OF  THE  STOMACH    (CARCINOMA  VENTRICULl)  33 1 

transmitted  to  the  tumor.  Intrinsic  movements  in  the  hypertrophied 
muscularis  may  cause  the  tumor  to  appear  and  disappear.  A  subcu- 
taneous umbilical  nodule  can  at  times  be  observed. 

Inspection  with  the  patient  standing,  as  suggested  by  Knapp,  should 
be  carried  out  in  any  case,  as  the  tumor  can  at  times  be  thus  more  readily 
appreciated.     Frequently,  simple  inspection  gives  no  information. 

2.  Percussion. — There  is  dulness  on  percussion,  or  a  dull  tympanitic 
note  over  the  tumor,  which  can  be  differentiated  from  the  surrounding 
tympanites.  Auscultatory  percussion  for  its  determination  is  described 
and  illustrated  in  Chapter  V. 

Smithies^  describes  a  new  percussion  sign  when  the  cancer  involves  the 
fundus  or  anterior  wall  of  the  body  of  the  stomach.  "  When  the  patient 
is  in  the  dorsal  position,  percussion  of  Traube's  space  is  not  uncommonly 
dull,  instead  of  normally  tympanitic.  Examination  of  the  same  area  at 
the  end  of  deep  inspiration,  or  upon  the  patient  lying  on  the  right  side,  or 
standing,  sometimes  results  in  the  disappearance  of  the  dull  tones  upon 
percussion  of  Traube's  space  and  the  appearance  of  characteristic  tym- 
pany. This  sign  was  observed  in  18  out  of  24  cases  of  carcinoma  involv- 
ing the  superior  portion  of  the  stomach  where  an  epigastric  tumor  could 
not  be  palpated." 

3.  Palpation. — ^This  is  usually  quite  reliable.  It  determines  the 
position  and  size  of  the  growth,  whether  hard  and  nodular  or  smooth, 
its  respiratory  motility,  and  whether  it  is  painful. 

It  is  difficult  to  recognize  a  tumor  on  the  posterior  stomach-wall 
unless  it  is  thin  and  the  stomach  empty.  On  the  lesser  curvature,  with 
the  stomach  in  the  normal  position,  it  can  only  be  felt  on  forced  inspiration. 

4.  Respiratory  Motility. — Tumors  of  the  curvatures  show  greater 
respiratory  motility  than  those  of  the  pylorus.  When  the  latter  is 
adherent  to  the  liver,  it  follows  the  excursion  of  the  diaphragm. 

Tumors  are  smaller  to  the  palpating  finger  than  they  are  found  to  be 
on  operation. 

5.  Inflation. — This  is  of  value  in  aiding  inspection  and  also  in  deter- 
mining whether  the  growth  is  connected  with  the  stomach,  if  it  be  ad- 
herent, and  in  some  cases,  the  position  of  the  tumor  in  the  organ.  Air 
can  be  employed  for  the  purpose,  or,  more  easily,  carbonic  acid  gas,  by  the 
method  already  described. 

If  the  tumor  lies  in  close  contact  with  the  liver  and  moves  away 
from  it  during  inflation,  the  diagnosis  of  tumor  of  the  stomach  is  evident, 
and  the  liver  and  gall-bladder  are  excluded.  If  this  does  not  occur, 
there  may  be  adhesions,  or  involvement  of  both  organs.  If  the  tumor 
changes  its  position  during  inflation,  there  are  probably  no  marked 
adhesions  with  the  neighboring  organs,  an  important  fact  in  reference  to 
operative  procedure. 

A  tumor  of  the  pylorus  generally  moves  to  the  right  and  downward  on 
inflation;  and  if  held  in  this  position  by  the  hand  will  not  ascend  during 
expiration — expiratory  fixation  (Minkowski).  If  adherent  to  the  liver, 
it  will  move  upward. 

Tumors  of  the  posterior  wall  and  lesser  curvature  that  are  palpable 
'  Cancer  of  the  Stomach,  Smithies  and  Ochsner,  1916. 


332 


DISEASES   OF  THE   STOMACH  AND  INTESTINES 


before  inflation  are  frequently  no  longer  so  thereafter.     With  gastroptosis, 
however,  the  tumor  would  be  palpable,  but  lie  higher  up. 

A  tumor  of  the  greater  curvature  descends  when  the  stomach  is  in- 
flated and  occupies  the  lowest  border  of  the  area  of  inflation;  it  is  freely 
movable  on  respiration. 

The  position  of  the  tumor  should  be  marked  on  the  abdominal  wall 
before  inflation  for  a  basis  of  comparison.  Inflation  of  the  colon  some- 
times aids  in  the  location  of  the  growth. 

6.  Transillumination  of  the  Stomach. — This  method  is  of  value  for 
the  early  recognition  of  a  tumor,  but  only  if  it  lies  on  the  anterior  surface, 
on  the  curvatures,  or  at  the  pylorus.  With  the 
circumscribing  gastro-diaphane  the  lesser  curva- 
ture can  be  explored.  The  method  with  fluores- 
cent media  is  preferable.  The  tumor  being 
opaque,  appears  as  a  dark  spot  projecting  into, 
or  within,  the  transilluminated  area;  on  top,  when 
the  lesser  curvature  is  involved;  below,  if  the 
greater  curvature;  to  the  right,  if  the  pylorus 
(Fig.  i88). 

Temperature. — This  is  not  a  regular  symptom, 
but  often  appears  in  the  later  stages.  It  oc- 
curred in  74  of  .Osier's  150  cases.  It  is  of  an  in- 
termittent type  and  rarely  runs  over  ioi°F.  Chills 
have  occasionally  been  associated.  Fever  is  prob- 
ably due  to  some  inflammatory  process,  or  to 
toxic  absorption  from  the  growth. 

Constipation  occurs  in  the  majority  of  cases 
and  is  obstinate  and  marked;  occasionally  there 
is    diarrhea,    due    to  food  decomposition  or  to 
scybalae,  causing  irritation  of  the  intestinal  canal, 
or  as  a  terminal  symptom  due  to  sloughing  of  the  cancer. 

Coma^  similar  to  diabetic  coma  may  occur,  and  is  believed  to  be  due 
to  acid  intoxication. 

Thrombosis  of  the  femoral  vein  is  an  occasional  symptom.  Osier 
reports  general  thrombosis  of  the  superficial  veins  in  one  case. 

Edema. — Swelling  of  the  ankles  frequently  occurs  toward  the  close, 
ascites  and  general  anasarca  sometimes  are  present,  and  the  latter  may 
appear  early. 

Metastases  have  already  been  described.     A  small  nodule  appearing 
at  or  near  the  umbilicus,  and  though  rather  rare,  may  aid  in  the  dagnosis. 
Multiple  neuritis  is  an  occasional  complication. 
Perforation  is  rare. 

Tetany  is  a  rare  complication,  but  has  occurred  with  malignant  stenosis 
of  the  pylorus  with  ectasia. 

Urine. — Excessive  nitrogen  excretion  has  been  found  in  some  cases, 
but  it  is  not  constant.     Salkowski^  and  Kojo  have  worked  out  a  method 

*  In  the  terminal  stage  of  cancer,  the  patient  becomes  bed  ridden,  there  may  be 
metastasis  of  the  lungs  or  hypostatic  congestion  occurs,  with  rapid  respiration,  rapid 
and  feeble  pulse,  irregular  temperature,  being  in  a  dormant  or  semi-comatose  condi- 
tion, with  resulting  coma  and  death. 

2  Berliner  klin.  Wochenschr.,  Dec.  12,  xlvii,  No.  50. 


Fig.  188. — Composite 
from  three  patients  show- 
ing dark  areas  in  trans- 
illuminated  stomach,  pro- 
duced by  carcinomata  of 
the  curvatures  and 
pylorus. 


CANCER  OF  THE   STOMACH   (CARCINOMA  VENTRICULl)  333 

for  determination  of  the  nitrogen  precipitated  by  salts  of  the  heavy  metals 
in  relation  to  the  total  nitrogen  output.  The  average  in  the  urine  of 
lo  healthy  persons  was  1.22  per  cent.,  while  in  10  cancer  patients  it 
averaged  3.03  per  cent.,  the  maximum  being  4.62  per  cent.  The  minimum 
2.15  per  cent.,  was  never  reached  in  healthy  urine.  These  facts  are 
suggestive,  but  further  investigation  must  be  made  to  see  if  these  findings 
are  pathognomonic  of  malignant  disease.  Diminution  of  the  chlorids  is 
quite  frequent,  while  indicanuria  is  common.  Glycosuria,  acetonuria, 
and  peptonuria  have  been  described. 

Peptonuria  indicates  absorption  from  an  ulcerated  area.  Nephritis 
is  often  present,  but  would  be  expected  in  advanced  age. 

Special  Symptoms  F*roduced  by  the  Location  of  the  Growth. — (a) 
Cancer  of  the  Cardia. — One  of  the  first  and  an  important  symptom  is 
dysphagia.  The  patient  finds  that  there  is  some  impediment  to  the 
entrance  of  solid  food  into  the  stomach  and  assists  it  by  drinking  water. 
The  condition  gradually  grows  worse.  Later,  it  is  impossible  to  take 
solid  food  at  all,  as  it  sticks  in  the  esophagus,  causing  much  discomfort, 
and  is  finally  regurgitated,  often  with  considerable  straining  or  retching. 
Finally,  most  of  the  fluid  even  is  returned.  There  are  often  severe  pains 
behind  the  end  of  the  sternum  and  burning  sensations.  Mucus  is  some- 
times ejected  with  the  food,  and  occasionally  blood.  The  cervical 
lymph-glands  are  often  enlarged.  Bronchitis  or  bronchopneumonia  are 
frequent  terminal  events. 

Physical  Examination. — The  stomach  is  of  normal  size  or,  in  some 
cases,  contracted;  the  swallowing  sound  is  occasionally  absent  or  heard 
in  fifteen  to  twenty  seconds  instead  of  in  the  normal  period  of  seven, 
though  this  is  not  invariably  true. 

Examination  of  the  esophagus,  preferably  with  soft  stomach-ttibes 
of  different  sizes,  should  be  made.  The  position  of  the  stricture  can 
be  noted  by  marking  on  the  tube  at  the  teeth  when  resistance  to  its 
passage  is  first  encountered,  and  measuring  the  distance  from  the  mark 
to  the  tip  of  the  tube.  Smaller  tubes  are  then  employed,  until  one  of 
sufficiently  small  caliber  is  secured  to  enter  the  stomach. 

In  this  way  the  degree  of  stenosis  can  be  determined.  Much  force 
should  never  be  used.  In  some  cases  it  may  be  necessary  to  employ  a 
stiff er  tube  of  silkworm,  or  bougies  of  varying  sizes.  The  author's  flexible 
esophageal  bougie  is  a  safe  instrument. 

The  soft  stomach-tube,  with  openings  at  the  tip  and  side,  is  of  value 
for  safety;  by  pinching  the  tube  before  withdrawal,  blood,  either  fresh  or 
decomposed,  of  foul  odor  or  mixed  with  mucus,  may  be  found  within  it, 
which,  in  conjunction  with  the  other  symptoms,  is  suggestive  of  malig- 
nancy. Occasionally  a  small  tumor  fragment  may  be  removed,  which 
should  be  submitted  to  microscopic  examination.  With  malignant 
stricture  of  the  esophagus,  dilatation  above  the  point  of  stenosis  and 
retention  of  food  are  associated.  It  also  occurs  in  benign  stricture  from 
syphilis  or  from  traumatism  from  burns  by  acids  or  alkalis,  or  with  con- 
genital stenosis  of  the  esophagus,  a  rare  condition. 

After  the  ingestion  of  suspended  bismuth  subcarbonate,  examina- 
tion with  the  x-rays  and  the  fluoroscope  will  aid  in  determining  the 


334  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

site  of  the  stricture.  This  is  of  special  value  when  it  is  not  desirable 
to  use  the  bougie.  A  rontgenograph  should  be  taken.  The  complete 
methods  of  examination  are  described  under  Examination  of  the  Esoph- 
agus and  Esophageal  Diseases,  under  which  section  is  depicted  the  Writer's 
flexible  bougie. 

Aspiration  of  the  esophagus  above  the  seat  of  stricture  after  a  small 
test-meal,  and  then  the  passage  of  a  smaller  tube  and  aspiration  of  the 
stomach  contents,  and  a  differential  examination  of  the  contents  are  not 
necessary  for  diagnosis,  though  they  have  been  recommended. 

The  food  removed  from  the  esophagus  would  present  the  appear- 
ance as  when  swallowed,  and  there  would  be  no  hydrochloric  acid;  while 
in  the  stomach  the  particles  would  be  finer,  the  reaction  acid,  and  free 
hydrochloric  acid  might  or  might  not  be  present.  This  is  also  true  of 
the  ferments.  It  has  been  demonstrated  by  Moore  and  Friedenwald'^ 
that,  in  cancer  of  other  organs  than  the  stomach,  there  may  he  diminution 
or  absence  of  free  hydrochloric  acid  in  the  gastric  contents,  and  this  occurs 
at  times  in  cancer  of  the  cardia.  The  presence  of  stricture  and  dysphagia^ 
the  age  of  the  patient,  and  the  general  symptoms  are  diagnostic. 

With  diverticula  of  the  esophagus,  which  usually  occur  at  the 
junction  of  the  pharynx  and  gullet,  there  is  generally  a  swelHng  in 
the  neck,  which  can  be  diminished  by  pressure  (the  contents  ex- 
pressed), and  symptoms  of  cancer  are  absent.  (See  also  Examination 
of  Esophagus). 

Spasm  of  the  esophagus  usually  occurs  in  nervous  patients,  and 
the  tube  when  passed  is  temporarily  arrested.  Larger  tubes  often 
pass  more  readily  than  the  small  ones.  There  are  no  symptoms  of 
malignancy.  With  persistent  cardiospasm,  fusiform  dilatation  of  the 
esophagus  may  result.  This  has  been  referred  to  and  the  rontgeno- 
graph depicted. 

(b)  Cancer  of  the  Pylorus. — The  chief  subjective  symptoms  are  pain, 
a  full-  feeling  in  the  stomach  and  other  dyspeptic  symptoms,  and  later 
frequent  attacks  of  vomiting.  Just  before  emesis  there  are  often  severe 
exacerbations  of  pain,  due  to  the  contractions  of  the  stomach  and  the 
effort  to  expel  the  contents  through  the  pylorus  (peristaltic  unrest). 

The  vomitus  is  generally  large  in  amount  (i  to  2  liters)  and  may 
consist  of  food  taken  the  day  before.  Motor  insufficiency  is  marked, 
the  contents  on  aspiration  being  found  to  consist  of  more  or  less  de- 
composed food,  when  the  fasting  stomach  is  examined.  The  particles  of 
food  are  often  quite  large  and  obstruct  the  openings  of  the  tube,  and  are 
difficult  to  remove  by  lavage.  Cancer  of  the  stomach  occurs  most  fre- 
quently at,  or  near  the  pylorus,  producing  as  noted,  food  remnants  in  the 
stomach;  as  more  than  50  per  cent,  of  cases  of  gastric  cancer  have  food 
remnants  according  to  Mayo,  the  sign  is  very  important  as  showing 
mechanical  obstruction. 

Physical  Examination. — Peristaltic  unrest  is  a  frequent  symptom  in 

more  advanced  obstruction.     Dilatation  of  the  stomach  is  present,  as 

determined   by   the   methods   of   examination   described.     Gastroptosis 

may  be  present.     Frequently  a  tumor  can  be  detected  lying  in  the  epi- 

^  N.  Y.  Med.  Jour.,  Aug.  24,  1907. 


CANCER  OF  THE  STOMACH    (CARCINOMA  VENTRICULl)  335 

gastrium  to  the  right  of  the  median  line  or,  if  ptosis  is  present,  at  a  lower 
level. 

(c)  Cancer  of  the  Body  of  the  Stomach. — Pain,  anorexia,  and  other 
symptoms  are  manifested.  Vomiting  occurs  in  some,  but  in  many 
case3  is  absent.  The  vomitus  contains  food  and  occasionally  coffee- 
grounds,  the  food  is  more  finely  divided. 

The  tumor  frequently  lies  to  the  left  of  the  median  line;  but  if  on  the 
upper  curvature  or  posterior  surface  of  the  stomach,  is  not  always 
detectable. 

There  is  motor  insufficiency  of  a  slight  or  moderate  degree  due  to 
infiltration  of  the  muscular  tissue  by  the  growth,  and  occasionally,  if 
the  tumor  be  large  and  on  the  greater  curvature,  a  slight  dilatation. 

On  the  other  hand,  in  the  transition  cases  from  ulcer  to  cancer,  there 
may  be  only  an  exacerbation  of  ulcer  symptoms  with  increasing  anemia, 
loss  of  strength,  etc.,  with  no  tumor. 


Fig.  189. — Gastric  contents  in  carcinoma.  Dark  ground  illumination  X  460; 
a,  Leukocyte;  b,  Boas-Oppler  bacilli;  c,  squamous  epithelium;  d,  yeast;  e,  mucous 
membrane  fragment  with  carcinomatous  cells  as  rarely  found  in  wash- water; /,  bacilli; 
g,  wheat  starch  grain;  h,  sarcinas  (very  rare);  i,  fat-droplet;  j,  cocci. 

Laboratory  Diagnosis. — In  conjunction  with  the  cUnical  symptoms, 
analysis  of  the  gastric  contents  and  microscopic  examination  aid  in  de- 
termining the  diagnosis  of  cancer  of  the  stomach  in  well-established  cases, 
while  in  the  early  cases  it  frequently  will  not  do  so. 

Gastric  Contents. — Golding  Bird,  in  1842,  first  refers  to  the  diminu- 
tion or  absence  of  hydrochloric  acid  in  gastric  cancer,  but  Von  der 
Velden,  in  1879,  first  studied  the  question  in  a  scientific  manner. 

For  accuracy  the  vomitus  should  be  examined;  analysis  of  the  gastric 
contents  and  microscopic  examination,  after  the  test-breakfast,  should 
be  made  and  the  stomach  washed  out.  If  small  fragments  of  mucosa  are 
found,  these  should  be  examined. 

Vomitus. — Macroscopically,  undigested  meat-fibers  and  coarse  food 


33^^ 


DISEASES   OF   THE   STOMACH   AND   INTESTINES 


panicles  are  found;  the  quantity  is  variable,  depending  upon  the  motor 
functions.  Coffee-ground  material  is  present  in  many  cases  and  often  a 
foul  odor  in  advanced  cases. 

Microscopically,  undigested  muscle-fibers,  remnants  of  vegetable 
material,  starch  granules,  fat-droplets,  numerous  fungi;  sarcina  are 
rare;  yeast-cells  are  found  in  stagnating  contents,  though  usually  as 
isolated  specimens;  and  blood  and  Boas-Oppler  bacilli  (Fig.  189).  Boas 
and  Strauss  report  pus^  in  some  cases.  Palier^  holds  that  staphylococci 
are  present  in  the  gastric  contents  of  cancer. 

Occult  blood  should  be  tested  for  by  Weber's  or  the  benzidin  or 
aloin  test,  if  none  appear  microscopically. 

Examination  of  the  Test-breakfast. — Ewald's 
or  Boas'  test-breakfast  should  be  given,  and 
one  hour  later  the  contents  aspirated  and  ex- 
amined. Repeated  analyses  should  be  made. 
Residuum  of  over  100  c.c.  at  the  end  of  an  hour 
and  particularly  if  there  are  larger  quantities 
with  food  remnants  from  a  preceding  meal, 
even  if  there  is  as  yet  no  vomiting,  shows  inter- 
ference with  emptying  of  the  stomach  and  is  a 
suspicious  circumstance  taken  in  connection  with 
the  other  symptoms  and  the  gastric  findings. 

I.  Hydrochloric  Acid. — Out  of  94  of  Osier's 
cases  of  gastric  cancer,  in  84  free  hydrochloric 
acid  was  absent;  and  in  40  cases.  Boas  found 
it  absent  in  35;  while  Graham  and  Guthrie  foimd 
in  150  cases  of  cancer  of  the  stomach  in  the 
Mayos  clinic  that  free  hydrochloric  acid  was 
absent  in  only  80  cases.  In  the  first  stages  of 
gastric  carcinoma,  however,  free  HCl  is  dimin- 
ished, not  absent.  A  progressive  diminution 
in  the  percentage  of  free  HCl  during  the  course  of  a  month  or  more,  as 
determined  by  frequent  examinations,  when  taken  in  consideration  with 
the  other  symptoms,  is  corroborative  of  cancer.  Einhorn  reports  6  cases 
of  gastric  cancer  in  which  free  hydrochloric  acid  was  present  in  normal  or 
excessive  quantity. 

Smithies  finds  that  practically  i  out  of  every  3  cases  of  gastric  cancer 
with  food  retention  has  free  HCl  above,  an  average  of  twenty-six  in  the 
fasting  stomach  contents  (retention). 

In  gastric  cancer,  engrafted  on  gastric  ulcer,  free  HCl  (or  hyper- 
chlorhydria)  has  been  noted  in  the  earlier  stages,  often  with  progressive 
diminution  accompanying  the  increased  development  of  the  cancer. 
I  have  seen  hyperchlorhydria  persist  in  quite  an  advanced  stage,  notably 
in  a  case  at  the  Red  Cross  Hospital.  The  patient,  aged  sixty-eight,  suf- 
fered with  the  symptoms  of  gastric  ulcer  for  a  year,  falling  off  in  weight 
from  240  to  2CX)  pounds.     There  was  then  a  slight  gain.    Later,  he  lost 

1  Pus  may  be  found  in  benign  ulceration,  as  in  Connors'  case,  as  well  as  in  malignant 
ulcer. 

2  N.  Y.  Med.  Record,  Nov.  19,  1904. 


Fig.  190. — Carcinoma  of 
stomach,  anterior  wall  in- 
volving greater  curvature; 
slight  reduction  of  motor 
function.  Tumor  evident 
by  palpation,  percussion, 
and  gastro-diaphany.  His- 
tory of  ulcer  with  carci- 
noma engrafted.  Hyper- 
chlorhydria present. 


CANCER  OF  THE   STOMACH    (CARCINOMA  VENTRJCULl)  337 

Steadily,  and  when  admitted  to  the  hospital  weighed  149  pounds,  was  ex- 
tremely weak  and  cachectic,  with  a  tumor  on  the  anterior  surface  of  the 
stomach,  involving  the  greater  curvature,  and  with  the  cUnical  symptoms 
of  carcinoma,  except  the  gastric  findings,  which  were  hyperacid,  with  a 
total  acidity  of  90+,  free  hydrochloric  acid  70+.  The  position  of  the 
growth  is  shown  in  Fig.  190.  There  was  only  slight  disturbance  of  motor 
function  and  no  vomiting.  Anemia,  leukocytosis,  and  eosinophilia  were 
present.  This  case  was  deemed  inoperable  and  was  under  trypsin  treat- 
ment some  years  ago,  when  some  advocated  its  trial. 

The  patient  gained  20  pounds  in  weight  under  treatment  and  proper 
diet,  and  was  able  to  go  out  daily.  From  his  ultimate  experience  with 
trypsin,  the  writer  was  obliged  to  con- 
clude that  the  diet  and  treatment  of  the 
hyperacidity  were  the  main  factors.  His 
strength  markedly  improved,  as  well  as 
his  appearance.  The  growth  did  not  dis- 
appear. The  patient  returned  to  work 
and  at  the  end  of  several  months  con- 
tracted pneumonia  and  died. 

We  know  that  free  hydrochloric  acid 
is  markedly  diminished,  or  even  absent, 
in  severe  catarrhal  gastritis,  and  is  absent 
in  achylia  gastrica.  Moreover,  hypo- 
chlorhydria  (diminished  acidity)  or  even  ^ig.  191.— Boas-Oppler  bacillus 

absence  of  free  hydrochloric  acid  per  se      from  near  top  of  fluid  from  wash- 
are  not  always  of  diagnostic  significance      '"S  i'i  case  of  gastric  cancer.    Ob- 
-  ^■1  ...      ,     ?  ,      /?    ,.         •  servation    at    Pennsylvania    Hos- 

01  cancer.     Keilmg^  gives  the  findmgs  m      pitai  (Boston). 

4937  stomach  cases,  and  in  these,  exclud- 
ing ulcer,  every  seventh  man  and  fifth  woman  had  no  free  hydrochloric  acid. 
This  condition  was  frequently  associated  with  disease  of  other  organs.  No 
free  HCl  was  found  in  30  per  cent,  of  254  cases  of  gall-stones,  and  in 
from  30  to  40  per  cent,  of  diabetes,  gout,  renal  calculus,  and  tuberculosis. 
Diagnosis  was  only  possible  after  the  test-breakfast.  The  absence  of 
HCl  is  not  pathognomonic  of  cancer,  but  taken  in  conjunction  with  the 
clinical  symptoms  is  confirmatory. 

2.  Lactic  Acid. — It  has  been  known  for  some  years  that  organic 
acids  were  increased  in  cancer  of  the  stomach  and  lactic  acid  was  present; 
but  to  Boas  must  be  given  the  credit  of  attaching  diagnostic  signifi- 
cance to  it,  and  who  first  described  exact  quantitative  and  qualitative 
methods. 

He  washes  the  stomach  and  gives  a  plate  of  barley  soup,  which  con- 
tains no  lactic  acid,  and  an  .hour  later  aspirates  the  contents.  Lactic 
acid  should  be  examined  for  by  Ufifelmann's  test  or  by  Boas'  method. 
Ewald's  test-breakfast  will  often  suflSce  for  practical  purposes. 

In  most  cases  lactic  acid  is  present  in  considerable  quantity,  though 
occasionally  it  is  absent   when  free   hydrochloric  acid   is   in  evidence. 
In  non-malignant  stenosis  with  dilatation  it  has  been  found,  so  it  can- 
not be  said  to  be  absolutely  pathognomonic.     The  absence  of  free  hydro- 
^  Archiv  fur  Verdauungskrankheiten,  Oct.^  1909. 


338  DISEASES    OF   THE    STOMACH   AND   INTETSINES 

chloric  acid  and  the  presence  of  lactic  acid  are  confirmatory,  in  conjunction 
with  other  symptoms. 

Boas-Oppler  Bacilli. — Boas-Oppler  bacilli  are  found.  These  are  rods 
of  considerable  length,  frequently  joined  at  their  ends,  and  form  long 
angulated  threads,  stainable  by  methylene-blue  or  other  anilin  dyes 
(Fig.  191).  They  must  be  distinguished  from  the  Leptothrix  buccalis 
(found  in  the  mouth).  A  drop  or  two  of  Gram's  solution  should  be  added 
to  the  specimen.  The  Boas-Oppler  stains  brown  with  the  iodin.  the  lepto- 
thrix, blue. 

Gram's  solution  consists  of  iodin,  i  part;  potassium  iodid,  2  parts; 
water,  300  parts. 

The  Boas-Oppler  bacillus  is  found  in  about  80  per  cent,  of  cases  of 
carcinoma  of  the  stomach;  also  rarely  in  non-malignant  stenosis  with 
dilatation  of  the  organ.  Smithies  demonstrated  this  in  93  per  cent,  out 
of  140  cases  of  gastric  cancer. 

With  absence  of  HCl,  an  alkaline  medium,  and  absence  of  stagna- 
tion, Paul  Cohnheim  also  holds  that  the  Trichomonas  hominis,  Megas- 
toma  entericum,  with  associated  amebae,  pus,  and  blood,  are  found  in 
carcinoma  of  the  stomach,  not  affecting  its  motility. 
•  Pus. — The  detection  of  pus  in  the  gastric  contents  by  microscopic 
examination  is  of  diagnostic  value. 

Blood. — The  presence  of  blood,  or  occult  blood,  is  also  important 
before  the  tumor  is  palpable.  Blood  in  some  form  was  found  in  73 
per  cent,  of  1000  cases  in  the  Mayo  Clinic. 

Rectal  examination  in  all  suspected  cases  of  carcinoma  of  the  stomach 
should  be  made  for  Blumer's  shelf.  This  consists  of  a  sharp  shelf-like 
process  lying  just  above  the  prostate,  felt  on  digital  examination  in  males; 
also  a  process  in  the  female  about  the  cervico-corporeal  portion  of  the 
uterus  in  Douglas  cul-de-sac.  This  shelf  is  due  to  a  secondary  deposit  or 
metastasis.  When  it  is  present,  operation  is  futile.  John  Erdmann  calls 
this  to  our  attention  particularly  in  an  instructive  article  on  Gastric 
carcinoma.^ 

Diagnosis. — Specific  Tests  for  Cancer. — Glycyltryptopkan  and  Trypto- 
phan Tests  for  Carcinoma  of  the  Stomach. — This  test,  devised  by  Neubauer'^ 
and  Fisher^,  in  December,  1909,  depends  on  the  fact  that  the  digestion 
of  proteins  proceeds  further  in  a  carcinomatous  stomach  than  in  a  normal 
one.  This  is  due  to  the  presence  of  an  enzyme  from  the  carcinoma,  which 
exhibits  strong  proteolytic  powers,  and  which,  like  trypsin,  is  capable  of 
converting  proteins  as  well  as  simple  peptids  into  amino-acids.  Pepsin 
can  only  digest  proteins  to  albumoses  and  peptones.  These  investigators 
have  utilized  these  facts,  and  use  an  amino-acid,  tryptophan,  which  in 
peptid  combination,  as  glycyltryptophan,  cannot  be  digested  by  pepsin 
and  does  not  give  a  color  reaction  with  bromin,  but  when  the  tryptophan 
is  split  by  tryptic  ferments  (carcinoma)  a  reddish-violet  color  or  reddish- 
pink  results,  when  bromin  vapor  is  added. 

It  has  been  demonstrated  that  solutions  of  glycyltryptophan  added 
directly  to  cultures  of  bacteria  grown  from  saliva  are  readily  split  with 

^  Med.  Record,  July  3,  1915. 

-  Bull.  Johns  Hopkins  Hosp.,  191 1,  xxii,  150. 

3  Deutsch.  Arch,  fiir  Klin.  Med.,  xcvii,  449,  1909. 


CANCER    OF   THE    STOMACH    (CARCINOMA   VENTRICULl)  339 

liberation  of  free  tryptophan.  Free  tryptophan  is  also  met  with  in  salivas 
when  there  are  dirty  or  infected  oral  cavities.  Smithies^  holds  that 
while  the  agent  in  saliva  causing  the  cleavage  of  glycyl tryptophan  has 
some  characteristics  of  an  enzyme,  it  seems  that  a  considerable  factor  in 
such  cleavage  power  is  the  action  of  normal,  or  pathologic  oral  micro- 
organisms, or  products  of  their  growth.  These  factors  would  therefore 
render  the  test  uncertain. 

Weinstein  holds  that  glycyltryptophan  is  unnecessary  and  tests  the 
gastric  filtrate  directly  for  tryptophan.  Blood,  bile,  swallowed  saliva, 
bacteria,  free  hydrochloric  acid,  peptid  splitting  bacteria,  and  regurgitated 
duodenal  contents  are  regarded  by  some  as  interfering  with  the  tests, 
while  others  claim  there  is  interference  by  some  of  these  and  not  by 
others.  Smithies^  shows  that  in  proved  cases  of  cancer  of  the  stomach 
more  than  one-third  gave  positive  glycyltryptophan,  and  one-thirteenth 
tryptophan  reactions  but  in  all  these  cases  the'  diagnosis  was  possible 
without  these  tests.  The  glycyltryptophan  reaction  occurred  more 
frequently  in  cancer,  but  in  many  cases  other  than  cancer  it  also  occurred. 

Friedman^  has  tested  this  reaction  and,  though  finding  it  positive  in 
many  cases,  does  not  look  upon  it  as  pathognomonic  of  cancer.  He  be- 
lieves the  tryptophan  test  to  be  worthless. 

Though  the  author  described  these  tests  at  length  in  his  previous  edi- 
tion and  advocated  their  employment,  he  now  feels  that  they  are  unreliable 
and  are  of  no  assistance  in  the  early  diagnosis  of  cancer.  Improvements 
may  occur  which  may  later  cause  him  to  alter  his  opinion. 

For  the  early  diagnosis  of  cancer,  or  in  the  transition  stage,  the  develop- 
ment of  carcinoma  from  gastric  ulcer — with  hyperchlorhydria  or  even  a 
moderate  amount  of  HCl  being  present — one  must  depend  on  the  presence 
of  occult  blood,  pus  (microscopic) ,  and  if  no  tumor  is  palpable,  upon  pro- 
gressive anemia,  loss  of  weight,  and  progressive  weakness,  and  the  x-rays. 

In  the  early  stage  of  carcinoma,  when  no  history  of  previous  gastric 
ulcer  can  be  secured  and  when  there  are  merely  progressive  anemia,  loss 
of  weight,  weakness,  loss  of  appetite,  and  gastric  symptoms  with  considerable 
free  HCl  still  present,  in  a  patient  of  middle  age  such  symptoms  are  suggest- 
ive of  malignancy.  It  is  in  this  class,  as  well  as  in  the  suspected  transition 
cases,  when  frequently  no  tumor  is  palpable,  the  .r-rays  demonstrating 
changes  in  the  contour  or  lumen,  disturbance  of  peristaltic  waves  or  motil- 
ity that  the  author  believes  exploratory  laparotomy  for  the  purpose  of  diagno- 
sis is  indicated  with  the  addition  of  such  operative  procedure  as  is  required. 
The  writer  believes  that  not  until  the  medical  profession  can  be  educated  to 
this  view  point  will  we  secure  tJie  early  operation  for  and  cure  of  carcinoma 
of  the  stomach.  On  discovery  of  a  chronic  ulcer  at  operation,  radical  pro- 
cedures, and  not  gastro-enterostomy  alone,  should  be  carried  out. 

Antitryptic  Reaction  of  the  Blood  in  Cancer. — Brieger  and  Trebing* 
have  announced  that  they  have  determined  a  new  characteristic  of  the 
blood  in  cancer — namely,  a  marked  increase  in  the  power  of  the  blood- 

^Arch,  of  Int.  Med.,  Dec,  x,  No.  6,  1912. 

*Arch.  of  Int.  Med.,  Oct.  15,  1912.  Also  Cancer  of  the  Stomach,  Smithies  and 
Ochaner,  1916. 

'  Archiv  of  Diag.,  New  York,  April,  1911;  also  N.  Y.  Med.  Journal,  Aug.  17,  1912. 
*  Berl.  klin.  Woch.,  1908,  p.  1041. 


340  DISEASES    OF   THE    STOMACH  AND  INTESTINES 

serum  to  inhibit  the  proteolytic  activity  of  solutions  of  trypsin.  Fuld  and 
Gross^  employ  a  solution  of  casein  as  a  medium  of  digestion,  thus  differing 
in  technic,  while  Feldstein  and  WeiP  employ  the  viscosity  method.  All 
observers  agree  that  the  great  majority  of  cases  of  cancer  give  evidence  of 
increased  antitryptic  value  in  the  serum.  This  condition,  however,  has  been 
frequently  found  in  the  acute  infections,  such  as  pneumonia,  typhoid  fever, 
sepsis,  and  polyarticular  rheumatism;  in  chronic  infections,  notably, 
tuberculosis;  in  diabetes  and  severe  anemias;  and  in  Graves'  disease  almost 
constantly.  The  reaction  occurs  with  the  inauguration  of  artificial  feed- 
ing in  infants  and  with  the  onset  of  labor  and  persists  through  the  puer- 
perium.'  The  increase  in  the  antitryptic  index  cannot,  therefore,  be 
called  a  specific  symptom,  but,  on  the  other  hand,  the  absence  of  the  anti- 
tryptic reaction  in  the  blood  may  be  taken  generally  as  arguing  against 
the  existence  of  cancer.  ^  A  positive  reaction,  excluding  the  conditions  noted, 
argues  the  probability  of  cancer.^    The  writer  doubts  its  practical  value. 

Hemolysis  as  a  Diagtiostic  Method  in  Cancer. — By  recent  researches 
they  have  attempted  to  demonstrate  that  there  exists  in  the  blood-serum 
of  patients  afi^ected  with  cancer  a  certain  substance  or  substances  which 
are  capable  of  causing  destruction  of  the  red  blood-cells  of  patients  not 
cancerous.  Kelling  first  commented  on  this  occurrence,  and  Crile  ap- 
parently sets  store  by  the  method.  Weil  has  experimented  with  it,  and 
Smithies^  has  recently  reported  on  the  subject.  It  will  be  noted  that 
the  reaction  occurs  with  tuberculosis,  anemia,  syphilis,  and  occasionally 
with  normal  subjects.  The  author  does  not  believe  it  furnishes  accurate 
information.  Weil  believes  the  method  not  diagnostic,  but  a  positive  re- 
action may  be  cautiously  considered  as  an  auxiliary  to  the  diagnosis.' 

A  Skin  Reaction  in  Cancer. — Based  on  the  same  hemolytic  action  of 
the  serum  of  cancerous  patients,  Elsberg^  and  Neuhof  conceived  the  idea 
of  bringing  the  red  cells  into  immediate  contact  with  the  serum  of  the 
cancerous  patient  in  vivo.  A  suspension  of  crushed  erythrocytes  in  saline 
solution  was  injected  under  the  skin  of  both  normal  and  cancerous  patients. 
About  five  hours  after  the  injection  a  reaction  appeared,  consisting  of  an 
oval,  irregular  reddish  area  from  2  to  5  cm.  long,  and  from  i  to  3  cm.  wide, 
at  times  surrounded  by  a  white  areola.  This  increased  in  intensity  for 
two  to  three  hours,  and  persisted  for  six  to  twelve  hours.  In  432  individu- 
als, 684  injections  were  given.  In  89.9  per  cent,  of  the  cases  in  which 
reaction  occurred,  there  was  a  positive  diagnosis  of  cancer,  and  in  94.3 
per  cent,  of  cases  with  no  reaction  it  was  possible  to  exclude  malignant, 
disease.  Lisser  and  Bloomfield*  hold  that  a  positive  skin  reaction  is' 
strongly  presumptive  of  cancer.  It  is  a  question  whether  this  reaction 
would  not  occur  with  other  conditions. 

^  Deutsch.  Arch.  f.  kKn.  Med.,  1908,  p.  319. 

*  Proc.  Soc.  Exp.  Biol,  and  Med.,  Feb.,  1910. 
'  Becker,  Miinch.  med.  Woch.,  1909,  p.  1363. 

*  Weil,  The  Antitryptic  Activity  of  Human  Blood-serum,  Amer.  Jour.  Med.  Sci., 
May,  1910. 

'  Jour.  Amer.  Med.  Assoc,  Oct.  29,  19 10. 

*  Med.  Rec,  Nov.  17,  1909. 

'  Jour.  Amer.  Med.  Assoc,  Oct.  29,  1910. 

*  Med.  Rec,  Oct.  15,  1910. 

*  Bulletin  Johns  Hopkins  Hospital,  Dec,  xxiii,  No.  262,  1912. 


CANCER   OF  THE   STOMACH    (CARCINOMA  VENTRICULl)  341 

Grafe  and  Rohmer^  claim  there  are  hemolytic  substances  in  the  stomachs 
of  cancer  patients.  This  never  occurs  in  the  healthy  subject  except  in  the 
presence  of  trypsin,  when  the  test  is  of  no  value.  A  negative  test  excludes 
malignancy,  a  positive  test  shows  an  ulcerating  surface,  cancer,  or  ulcer. 

Salomen^s  Test. — The  method  consists  in  washing  out  the  stomach  in 
the  evening,  and  then  on  the  following  morning  the  introduction  of  400 
c.c.  of  normal  salt  solution.  This  is  aspirated  out  after  a  short  stay  in 
the  stomach  and  tested  for  the  presence  of  albumin  and  for  the  proportion 
of  nitrogen. 

Marked  turbidity  with  Esbach's  reagent  (picric  acid)  or  the  presence 
of  more  than  30  milligrams  of  nitrogen  indicates  the  presence  of  carcinoma. 
It  cannot  be  considered  of  value  in  the  writer's  estimation. 

Wolff- Junghans  Test  for  Soluble  Albumen. — Smithies^  summarizes  his 
experience  with  this  method  in  747  cases  where  there  was  achylia  or  asso- 
ciation with  conditions  conf usable  with  malignancy.  •  In  78.4  per  cent, 
the  diagnosis  was  checked  by  operation.  He  found  the  test  positive  or  sus- 
picious in  80  per  cent,  of  the  series  of  gastric  cancer — of  which  there  were 
215  cases  proved  by  operation.     The  test  is  therefore  apparently  of  value. 

Silica  Metabolism. — Rohden  in  1902,  announced  that  the  pancreas 
is  a  reservoir  for  silicic  acid  in  the  organism  and  four  years  earlier  Kail 
made  a  study  of  silica  metabolism  in  cancerous  subjects  and  found  an 
amount  of  silica  in  the  pancreas  double  the  normal  content,  while  that 
excreted  by  the  urine  was  correspondingly  lessened.  Kahle  and  Rossle^ 
show  that  the  opposite  relationship  is  found  in  tuberculosis.  The  de- 
termination of  silica  content  in  the  urine  might  possibly  be  of  service  in 
the  diagnosis  of  internal  cancer. 

Urinary  Methylene-blue  Reaction  with  Cancer. — Fuhs*  claims  that 
methylene-blue  is  decolorized  by  the  urine  of  patients  suffering  from  cancer. 
Three  to  five  drops  to  Loffler's  methylene-blue  is  added  to  a  test-tube  of 
the  patient's  urine,  or  sufficient  to  give  it  a  decided  blue  color.  The  urine 
is  shaken  and  allowed  to  stand  for  twelve  to  twenty-four  hours  at  the 
room- temperature.  A  control  fresh  specimen  of  normal  urine  is  similarly 
prepared.  The  blue  color  of  the  urine  of  the  patient  disappears  at  the 
end  of  twenty-four  hours,  except  the  color  of  the  upper  layer  in  contact 
with  the  air.  The  normal  urine  retains  its  blue  color.  The  urines  of 
pregnancy,  rheumatism,  nephritis,  meningitis,  etc.,  particularly  of  preg- 
nancy, decolorize,  but  in  most  cases  the  test  is  negative  in  subsequent 
examinations  as  the  condition  of  the  disease  improves,  while  with  malig- 
nant disease  the  change  is  constant.  Verbrycke,^  after  a  series  of  tests, 
holds  the  method  of  no  value. 

There  are  many  other  tests  advocated  for  the  determination  of  cancer, 
but  the  author  believes  possibilities  lie  particularly  in  Van  Slyke's  modi- 
Jkation  of  the  Abderhalden  test. 

Lowy^  has  reported  on  the  Abderhalden  test  and  has  recently  investi- 

^  Deutsch.  Arch,  fur  klin.  Med.,  xciv;  also  Med.  Rec,  Aug.  19,  191 1. 

2  Cancer  of  the  Stomach  (Smithies  and  Ochsner),  1916.     W.  B.  Saunders  Co. 

'  Mvinch  med.  Woch.,  Apr.  7,  19 14. 

*  Jour.  Amer.  Med.  Assoc,  June  24,  191 1. 

»  Med.  Rec,  Oct.  28,  191 1. 

•Postgraduate,  1914,  xxix,  p.  914. 


342  DISEASES   OP  THE  STOMACH  AND  INTESTINES 

gated  the  Van  Slyke  method  of  amino-nitrogen  estimation  as  applied  to 
the  Abderhalden  test.  He^  reports  the  appUcation  of  Van  Slyke's  amino- 
nitrogen  determination  for  the  diagnosis  of  cancer  in  42  cases  of  cancer 
at  the  N.  Y.  Post  Graduate  School,  of  which  14  were  of  the  stomach, 
2  of  the  pylorus,  3  of  the  colon,  4  of  the  esophagus  and  the  balance  of 
the  breast  and  uterus.  There  were  83.3  positive  and  16.7  negative  in  the 
series.  In  nonmalignant  cases  examined,  out  of  44,  positive  15  per  cent., 
negative  85  per  cent. 

Other  Tests. — Boas-Oppler  Bacilli  in  the  Stool. — Neusser  and  R.  Schmidt 
hold  that  Boas-Oppler  bacilli  are  more  easily  found  in  the  stool  than  in 
the  gastric  contents  and  aid  early  diagnosis  of  cancer.  Gram-negative 
stools  exclude  cancer  of  the  stomach;  Gram-positive  stools,  uniform-sized 
Gram-positive  bacilli  (Boas-Oppler  bacilli),  show  cancer.^  I  believe  the 
Bacillus  aerogenes  capsulatus  are  found,  and  their  deductions  probably 
erroneous.  Anaphylaxis^  from  injection  of  cancerous  gastric  juice  into 
animals;  the  increase  of  amino-nitrogen  in  the  gastric  contents  WolflFs 
dissolved  albumin  test,  and  marked  urine  pepsin  have  been  suggested  as 
tests  for  cancer.  Some  suggest  gastroscopy  as  an  aid  to  diagnosis.  Suss- 
man  of  Berlin  has  invented  a  flexible  gastroscope  which  can  be  made  stiff 
after  insertion.  It  is  the  safest  instrument  so  far  devised,  though 
somewhat  complicated.  Gastroscopy  affords  us,  however,  insufl&cient 
information. 

Again  in  a  patient  of  forty  to  sixty  or  more  years  of  age,  suffering  from 
recent  gastric  disturbances  of  six  months'  or  a  year's  duration,  or  less,  with 
a  previous  history  of  good  health  or  of  former  gastric  ulcer,  there  being  con- 
tinuous pain,  frequently  epigastric  rigidity,^  rapid  loss  of  weight  and 
strength,  anorexia  with  or  without  vomiting,  motor  insufficiency  moderate, 
or  great  with  marked  ectasia  or  even  with  fair  motility,  with  free  HCl 
present  in  considerable  quantity,  diminished  or  absent;  lactic  acid  present 
or  absent;  Boas-Oppler  bacilli  present  or  absent;  whether  or  not  there  be 
tumor  detectable,  or  whether  or  not  coffee-grounds  are  present  in  the 
vomitus,  such  symptoms  should  be  considered  diagnostic  of  carcinoma  of 
the  stomach.  As  already  noted,  the  presence  of  pus  and  occult  blood  are 
important  when  found.     Exploratory  laparotomy  is  at  least  indicated. 

This  rule  is  given  particularly  for  the  benefit  of  the  country  practitioner 
who  may  not  have  the  facilities  of  the  .r-rays.  If  radiography  is  possible, 
the  changes  in  the  contour,  lumen,  peristalsis  and  motility  of  the  stomach 
render  the  diagnosis  more  positive. 

The  Mayos  now  frequently  send  a  patient  to  the  operating-room  with 
a  diagnosis  of  cancer  on  an  old  ulcer,  based  on  the  history  of  a  chronic 
ulcer  with  recent  exacerbation,  accompanied  by  loss  of  weight,  weakness, 
and  anemia  associated  with  the  radiological  findings  noted.  They  do 
not  wait  for  cachexia,  tumor,  and    the  text-book  test-meal. 

Rontgen  Rays. — The  oj-rays  aid  undoubtedly  in  the  early  diagnosis 
of  gastric  carcinoma,  or  at  least  demonstrate  a  surgical  condition  to  be 

^  Journal  A.  M.  A.,  May  8,  1915;  also  Journal  A.  M.  A.,  Sept.  11,  1915  (Levin- Van 
Slyke.) 

^P.  K.  Brown,  Jour.  Amer.  Med.  Assoc,  Nov.  6,  1909,  p.  1525. 

^Med.  Rec,  Aug.  19,  1911. 

*  Anders,  N.  Y.  Med.  Jour.,  Nov.  21,  1908. 


CANCER   OF   THE   STOMACH   (CARCINOMA  VENTRICULl)  343 

present.  They  are  of  paramount  importance.  The  new  growth  makes 
itself  evident  by  a  change  in  the  contour  of  the  stomach- wall;  by  dis- 
turbance of  the  peristaltic  waves  at  certain  points;  at  times  by  rigidity  and 
contraction  of  the  stomach- wall;  by  adhesions  which  prevent  the  free 
motility  of  the  stomach  when  the  abdominal  walls  are  contracted,  or  when 


PRONE    IMMEDIAmV  AFTER    BARIUM    MEAL 
^^^*  ^  SINCLAIR    TOUSEY    MD 


Fig.  192. — Case  diagnosis  "gastric  ulcer  with  early  malignant  degeneration."  At 
-|-  incisura  is  deeper  and  somewhat  irregular.  In  series  of  cinematographs  this  incisura 
-|-  on  greater  curvature  (pars  pylorica)  remains  constant,  while  the  upper  ones  on  lesser 
curvature  change  their  position.  This  is  therefore  a  "filling  defect."  Loss  of  20 
pounds  in  one  year;  lately  loss  more  rapid.  Feels  weak.  Total  acidity  60+;  free 
HCl  35 ;  comb.  HCl  22. 


the  position  of  the  patient  is  changed;  and  finally,  in  some  cases,  by  ob- 
struction to  the  passage  of  food.  In  the  early  stage  of  carcinoma,  dif- 
ferentiation between  this  and  chronic  ulcer  by  the  :v-ray  is  absolutely 
impossible.  This  is  all  the  more  evident  from  the  demonstration 
that  frequently  pathological  examination  will  alone  differentiate  these 
conditions. 

Radiologic  Findings  of  Carcinoma  of  the  Stomach. — i.  Large  rounded 
mass  may  project  into  stomach  and  prevent  barium  or  bismuth  from 
filling  this  portion.  If  the  body  or  fundus  are  involved,  there  is  no 
pyloric  obstruction. 

2.  Nodular  growths  show  "finger-print"  indentations. 


344  DISEASES  or  the  stomach  and  intestines 

3.  Obliteration  of  an  area  with  serrated  edges  of  uninvolved  area; 
occurs  with  a  destructive  process, 

4.  Funnel  appearance  from  an  annular  growth. 

5.  With  pyloric  obstruction  a  thin  distorted  line  of  bismuth  in  this 
region,  or  a  disappearance  of  the  pyloric  orifice  with  evidences  of  adhesions, 
or  a  worm-eaten  line  of  involvement;  dilatation  of  the  stomach  and  stasis 
occur. 

6.  With  scirrhus  cancer,  the  stomach  may  be  held  up  high  in  position, 
with  disturbances  of  motility  of  the  lesser  curvature. 

7.  Involvement  of  the  pars  media  does  not  cause  dilatation.  At  times 
the  stomach  empties  very  rapidly,  as  it  does  in  early  cases  of  carcinomatous 
ulcer  near  the  pylorus  when  there  is  no  stenosis. 

The  radiological  findings  of  early  cases  {transition  of  ulcer  to  cancer) 
are  the  same  as  ulcer.  As  an  illustration  of  this,  note  Fig.  192.  This 
patient  at  +  has  a  filling  defect — history  pointing  to  gastric  ulcer;  loss  of 
weight  20  pounds  in  one  year — most  of  it  more  recent.  Patient  feels  weaker 
recently.  Aged  forty-seven  years;  woman.  No  blood  contents  found  in 
gastric  or  stool  at  examination.  Total  acidity  60-i- ;  free  HCl  35  + ;  comb. 
HCl  22-}-;  and  salts  3-}-.  Gastroptosis.  Some  adhesions  to  transverse 
colon.  Motility  of  stomach  good.  This  case  is  in  the  writer's  opinion, 
an  early  manifestation  of  cancerous  degeneration  of  a  chronic  gastric 
ulcer.  The  gastric  analysis  should  not  figure,  and  on  the  strength  of  the 
clinical  symptoms  plus  the  radiographs,  the  case,is  at  once  referred  to  the 
surgeon  for  radical  operation  (resection  of  the  stomach). 

The  method  is  an  aid  in  connection  with  the  clinical  symptoms  and 
physical  and  clinical  examination  and  demonstrates  even  in  early  cases 
that  a  surgical  condition  is  present.  It  will  not  always  be  possible,  however, 
to  differentiate  in  the  early  stage  between  a  benign  chronic  ulcer  and  a 
malignant  condition.  The  reader  is  referred  to  the  section  on  the  "  X-rays 
in  Gastro-intestinal  Diseases"  for  a  complete  description  of  the  radiological 
findings  in  gastric  cancer. 

Diagnosis. — In  conclusion  the  author  places  most  reliance  in  the  his- 
tory, age,  progressive  loss  of  weight,  progressive  anemia,  retention  of  gas- 
tric contents  pointing  to  mechanical  obstruction,  radiographs  showing 
irregularity  in  the  contour  of  stomach,  disturbance  of  motility,  and  bis- 
muth retention  (these  facts  pointing  to  a  surgical  condition),  and  the 
tumor  (when  present).  The  Abderhalden  or  preferably  Van  Slyke's  modi- 
fication and  Wolff- Junghans  are  the  only  tests  I  believe  at  present  of 
sufficient  value  to  employ — there  being  a  greater  percentage  of  positive 
results  than  with  the  others  advocated.  I  would  recommend  exploration 
with  the  conditions  noted  above,  even  though  serological  tests  were 
omitted,  and  no  tumor  was  palpable.  One  should  not  depend  on  the  typic 
gastric  analysis,  i.e.,  wait  for  its  appearance. 

Differential  Diagnosis. — Apparent  Tumors  of  the  Stomach. — Prolapse 
of  the  left  lobe  of  the  liver,  or  a  pulsating  aorta,  or  thickening  of  part  of 
the  abdominal  muscles  (recti)  are  referred  to  by  Einhorn  as  being  mistaken 
for  a  tumor  or  possibly  for  a  carcinoma  of  the  stomach.  In  view  of  the 
fact  that  with  these  conditions  gastroptosis  is  usually  associated,  the 
history  is  a  long  one,  emaciation  is  of  long  duration,  and  the  symptoms  of 


CANCER   OF  THE   STOMACH    (cARCINOMA  VENTRICULl)  345 

cancer  are  absent,  the  mistake  can  hardly  occur.  They  are  also  apt  to  be 
present  in  younger  patients.  Simple  adhesions  to  the  stomach  give  a 
history  most  frequently  of  gall-bladder  disease,  or  gastric  ulcer,  or  local- 
ized peritonitis.  Adhesions  are  frequently  present  with  cancer,  but  the 
symptoms,  radiologic  and  gastric  findings  are  of  carcinoma. 

Crave  Anemia  in  Carcinoma  Veniriculi,  without  Palpable  Tumor. — 
These  cases  must  be  differentiated  from  pernicious  anemia.  The  type 
occurs  with  mild  dyspeptic  symptoms.  The  blood-count  is  rarely  below 
2,000,000  per  cubic  millimeter;  there  is  absence  of  megaloblasts  and  leuko- 
cytosis is  present,  which  speak  for  cancer.  There  is  a  lower  color-index, 
as  in  secondary  anemia. 

In  addition,  the  acidity  of  the  gastric  contents  is  higher  in  cancer 
than  with  the  achylia  gastrica  of  pernicious  anemia,  and  lactic  acid  is 
present  in  cancerous  anemia.     The  gastric  findings  of  achylia  are  typic. 


Fig.  193.  Fig.  194. 

Fig.  193. — Syphilitic  sclerosis  of  stomach.  Physical  examination  of  stomach  sug- 
gests scirrhous  carcinoma  (dififuse)  of  stomach. 

Fig.  194. — Syphilis.  Enlargement  of  left  lobe  of  liver  overlapping  stomach. 
Transillumination  shows  mass,  which  is  readily  palpable.  Side  view  (gastrodiaphany) 
shows  the  mass  not  connected  with  the  stomach.     Free  HCl  trace;  chronic  gastritis. 

If,  therefore,  we  have  gastric  symptoms,  rapid  loss  of  weight,  and  severe 
anemic  symptoms  in  an  elderly  patient,  the  diagnosis  of  cancer  is  most 
probable.  With  secondary  anemia  or  chlorosis,  hyperchlorhydria  is 
usually  associated. 

Syphilis.- — This  may  present  symptoms  which  may  simulate  carcinoma 
of  the  stomach,  unless  thorough  examination  be  made.  I  have  seen  three 
types  of  this  class. 

I.  Sclerosis  of  the  Stomach. — A  male  patient,  aged  sixty,  had  lost 
30  pounds  in  weight  within  a  period  of  a  year;  was  emaciated  and  weak, 
sufifering  from  gastric  symptoms  and  constipation.  On  examination,  a 
small  hard  mass  was  found  in  the  epigastrium  at  the  left  border  of  the 
ribs  (Fig.  193). 

It  was  demonstated  to  be  a  hard  and  contracted  stomach,  giving 
the  feel  of  a  diffuse  scirrhous  carcinoma  of  the  organ.  The  liver  was 
diminished  in  size  and  hard.     Free  HCl  was  absent,  the  findings  were  of 


346 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


iter  ViSlbh  b^      _  _ 
Troftst  Hum  /  na/Joft 


achylia  gastrica.  Syphilitic  scars  were  in  evidence  and  the  patient 
acknowledged  syphilis  and  alcoholisiti.  The  demonstration  of  Wasser- 
mann's  reaction  is  diagnostic  in  doubtful  cases. 

2.  Cirrhosis  of  the  Liver  (Left  Lobe — Syphilitic). — Male,  aged  fifty- 
five,  had  lost  20  pounds  in  a  few  months  and  suffered  from  gastric  symp- 
toms. A  hard  mass  could  be  felt  in  the  epigastrium,  extending  down 
from  the  lower  border  of  the  left  ribs,  apparently  a  tumor  of  the  lesser 
curvature  of  the  stomach  involving  the  anterior  wall.  Respiratory 
movements  were  present.  Deep  palpation  elicited  a  free  edge,  and 
gastrodiaphany  showed  an  opaque  mass,  but  on  moving  the  instrument 
a  lateral  view  demonstrated  the  mass  overlapping  the  stomach  (Fig.  194). 
Gastric  findings  were  a  trace  of  HCl  and  much  mucus  (chronic  gas- 
tritis). Syphilitic  scars  and  history 
were  elicited.  Improvement  fol- 
lowed treatment  directed  to  the 
stomach  and  syphilis. 

3.  Syphilitic  Stenosis  of  the  Py- 
lorus, Due  to  Gummatous  Tumor, 
Simulating  Malignancy. — Male  pa- 
tient, aged  thirty-eight.  Weight, 
September,  1907,  196  pounds.  At 
this  time,  anorexia,  pain  continuous 
in  character,  nausea,  and  occasional 
vomiting  began.  These  symptoms 
gradually  grew  worse  and  the  patient 
steadily  lost  weight.  Early  in  No- 
vember he  entered  a  local  hospital, 
where  he  was  under  treatment  by 
lavage,  etc.,  for  eight  weeks.  His 
weight  on  leaving  the  institution  was 
137  pounds.  He  spent  two  months 
at  a  western  sanitarium,  where  he 
grew  steadily  worse,  having  vomited  small  quantities  of  blood  on  several 
occasions.  He  was  given  morphin  for  pain  and  subsequently  contracted 
the  habit. 

At  the  end  of  March,  1908,  or  about  six  and  a  half  months  after  the 
first  appearance  of  symptoms,  he  entered  the  Red  Cross  Hospital.  His 
weight  was  119  pounds,  a  loss  of  77  pounds,  epigastric  pain  nearly  con- 
tinuous, increased  some  after  eating,  tenderness  in  the  epigastrium, 
peristaltic  unrest  of  the  stomach,  dilatation  to  one  finger  below  umbilicus, 
vomiting  five  or  six  times  daily.  There  were  marked  emaciation  and  con- 
siderable anemia,  but  not  the  cachectic  appearance  of  cancer.  No  tumor 
was  detectable  by  palpation,  or  transillumination,  but  a  sense  of  resistance 
at  the  pylorus.  Frequent  gastric  analysis  invariably  showed  free  HCI 
absent  and  abundant  lactic  acid.  Morphin  was  shut  off,  and  lavage,  diet, 
and  careful  observations  were  carried  out.  A  syphilitic  history  was 
secured. 

On  account  of  the  age  of  the  patient,  the  syphilitic  history  and  the 
absence  of  true  cachexia,  in  spite  of  the  gastric  findings,  I  believed  the 


Fig.  !()<,. — Syphilitic  stenosis  of  pylorus 
due  to  gumma  simulating  malignancy. 
Transillumination  shows  dilatation,  but 
no  tumor.  Growth  found  at  operation 
lying  on  posterior  wall  of  pylorus.  Gas- 
tric findings  of  carcinoma,  but  no  cachexia. 


CANCER   OF  THE   STOMACH    (CARCINOMA  VENTRICULl)  347 


/iitpaUe  Tumor — 


stenosis  to  be  non-malignant  (syphilitic)  and  advised  operation.  This 
was  duly  performed.  There  was  a  hard  mass  on  the  posterior  wall  of 
the  pylorus,  about  the  size  of  an  English  walnut,  diagnosed  as  a  gumma, 
blocking  the  passage;  no  glandular  involvement  (Fig.  195).  As  the  patient 
was  in  poor  condition,  rapid  gastro-enterostomy  was  performed.  He 
vomited  once  after  operation.  Mercurial  inunction  and  iodids  were  given, 
and  the  patient  left  the  hospital  in  good  condition.  He  would  unques- 
tionably have  died  from  inanition  unless  stomach  drainage  had  been 
instituted,  in  spite  of  specific  treatment. 

In  reference  to  syphilis  of  the  stomach,  the  writer  wishes  to  report  the 
following  observations  to  which  he  believes  attention  has  not  previously 
been  called.  In  the  tertiary  stage  of  syphilis,  with  fibrosis  such  as  liver 
cirrhosis,  chronic  pancreatitis,  gummata,  etc.,  when  the  stomach  is  in- 
volved, we  may  have  many  of  the  gastric  findings  of  malignancy,  absence 
of  HCl,  presence  of  lactic  acid,  etc.,  associated  with  pyloric  stenosis,  simu- 
lating malignancy  as  reported  above. 
On  the  other  hand,  during  the  second- 
ary stage,  syphilitic  gastric  ulcer  may 
occur,  with  contraction  of  the  scar  and 
benign  stenosis  of  the  pylorus,  with  the 
typic  hyperchlorhydria  of  such  cases. 
These  features  will  be  referred  to  again 
under  Syphilis  of  the  Stomach. 

Cancer  Engrafted  on  an  Ulcer. — This 
condition,  I  believe,  is  a  frequent  occur- 
rence. It  is  now  held  that  70  per  cent, 
of  cancer  results  from  chronic  gastric 
ulcer.  In  some  cases  there  may  be  a 
gradual  change  in  the  symptoms  and 
character  of  the  gastric  secretion,  a 
gradual  diminution  of  free  HCl,  though 
Riegel  has  brought  to  our  attention 
that  in  this  type  the  excessive  produc- 
tion of  hydrochloric  acid  often  persists  for  a  long  time,  and  in  some  rapidly 
fatal  cases  may  be  present  until  death. 

In  these  cases  the  diet  and  medication  directed  to  the  ulcer  may  fail 
to  relieve  symptoms  as  soon  as  the  malignant  condition  sets  in.  The  pain 
increases  and  is  continuous.  There  is  a  dislike  or  even  loathing  for  food. 
There  is  rapid  loss  of  weight  and  the  typical  cachexia  appears — a  change 
from  the  facies  of  ulcer.  Hematemesis  is  more  frequent,  especially  as 
occult  hemorrhage,  and  not  in  the  larger  amounts,  such  as  with  ulcer. 

I  have  already  referred  to  a  patient  of  this  class  (hyperchlorhydria), 
with  a  marked  growth,  cancer  engrafted  on  an  ulcer. 

Aneurysm  of  the  Celiac  Simulating  Carcinoma  of  the  Pylorus. — The 
possibility  of  this  error  is  interesting.  A  negro  patient,  aged  forty-five, 
was  seen  by  me  at  Roosevelt  Hospital  some  years  ago  at  the  request  of 
William  H.  Thomson. 

The  illustration  (Fig.  196)  shows  the  position  of  the  stomach  by 
inflation  and  that  of  the  mass  by  palpation,  it  not  being  visible  by  trans- 


Fig.  196. — Aneurysm  of  celiac  axis 
with  symptoms  simulating  carcinoma 
of  pylorus.  No  tumor  visible  by 
transillumination.  Tumor  disappears 
on  inflation. 


348  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

illumination.  The  tumor  disappeared  on  inflation,  diagnostic  of  a 
posterior  position. 

There  were  vomiting,  gastric  symptoms,  such  as  pain,  anorexia,  etc., 
and  a  loss  of  weight  of  40  pounds  in  three  months.  The  patient  was  very- 
weak.  Dilatation  of  the  stomach  to  below  the  umbilicus.  Gastric  anal- 
ysis; no  free  hydrochloric  acid;  lactic  acid  was  present. 

A  palpable  tumor,  the  size  of  a  small  egg,  was  present  in  the  epi- 
gastrium, in  which  there  was  slight  pulsation,  but  no  bruit  or  thrill. 
From  the  history  and  results  of  examination  it  seemed  to  be  a  carcinoma 
on  the  posterior  wall,  involving  the  pylorus,  with  pulsation  transmitted 
from  the  aorta. 

The  possibility  of  aneurysm  was  considered.  Exploration  by  G. 
Brewer  showed  an  aneurysm  of  the  celiac  axis  pressing  on  the  pylorus 
posteriorly.  The  resulting  occlusion  of  the  pylorus,  and  the  circulatory 
disturbances  from  the  aneurysm  were  responsible  for  the  ectasia  and 
changes  in  the  gastric  secretion.  W.  L.  Rodman^  reports  a  case  of  ap- 
parently a  palpable  cancer  of  the  pylorus,  with  absence  of  free  hydro- 
chloric acid  and  the  presence  of  lactic  acid  in  the  gastric  contents.  The 
diagnosis  of  carcinoma  of  the  stomach  had  been  made  in  several  hospitals. 
Aneurysm  of  the  abdominal  aorta  was  found  at  operation. 

Syphilis  and  aneurysm  must  thus  be  considered  in  our  differential 
diagnosis. 

The  following  are  the  chief  diagnostic  points  between  cancer  of  the 
stomach  and  other  conditions: 

Cancer. — Age,  usually  forty  to  seventy;  active;  tongue  coated;  more 
frequent  in  males;  symptoms  progressive  and  of  short  duration — a  few 
months  to  a  year;  emaciation  rapid;  cachexia;  repeated  small  hemor- 
rhages, but  not  always;  pain  continuous,  not  paroxysmal,  with  no  periods 
of  relief,  and  not  referring  especially  to  the  digestion  period;  anorexia, 
vomiting  once  or  twice  a  day;  later,  coffee-grounds  in  vomitus;  at  times 
only  occult  blood  in  vomitus  or  stool;  ectasia  if  the  pylorus  is  involved; 
tenderness  over  the  gastric  region;  no  relief  of  pain  by  vomiting;  anemia; 
free  HCl  diminished  or  absent;  lactic  acid  present,  also  pus;  sarcinae  rare 
and  when  present,  few;  Boas-Oppler  bacilli  in  most  cases;, in  some  vomit- 
ing of  blood  (coffee-grounds),  small  in  quantity  and  often  repeated  several 
times;  melena  slight.  Presence  of  a  tumor.  Leukocytosis  moderate  and 
eosinophilia  present.  Mucus  present  in  some  cases.  Dysphagia  and  re- 
gurgitation if  involvement  is  at  cardia.     This  is  a  typic  progressive  case. 

Gastric  Ulcer. — Age  usually  twenty  to  forty;  more  frequent  in  females; 
pain  paroxysmal  and  worse  after  eating;  remissions  of  pain,  and  relieved 
by  vomiting;  pain  in  epigastrium  and  in  the  back;  local  circumscribed 
tenderness  in  the  epigastrium  increased  by  pressure,  at  time  slight  tender 
point  in  the  back;  loss  of  weight;  anxious  expression  of  suffering;  no 
cachexia;  anemia;  vomiting  at  height  of  digestion;  appetite  good;  hyper- 
chlorhydria  usual,  but  not  always;  vomiting  of  blood  in  large  quantity,  at 
times  of  bright  color;  melena.     Blood  at  times  only  occult. 

It  is  interesting  to  observe  that  the  Mayos  report  the  incidence  of 
gastric  ulcer  as  more  frequent  in  males.  As  a  rule,  men  will  not  devote 
^  Jour.  Amer.  Med.  Assoc,  Jan.  18,  1908,  vol.  i,  pp.  165-169. 


CANCER  OF   THE   STOMACH    (CARCINOMA  VENTRICULl)  349 

the  time  (rest  in  bed  for  four  weeks)  to  the  ulcer  cure,  on  account  of  the 
stress  of  business.  They  take  treatment  in  a  desultory  way  and  ulti- 
mately, I  believe,  a  larger  per  cent,  of  men  finally  resort  to  the  surgeon. 
As  far  as  I  can  secure  information,  the  general  practitioner  treats  more 
gastric  ulcers  in  women  than  in  men.  This  does  not  excuse  this  practice, 
in  the  case  of  chronic  ulcer,  which  should  be  treated  as  a  precancerous 
condition.     Cancer  moreover  is  a  little  more  frequent  in  the  male. 

Benign  Stenosis. — Dilatation  of  stomach;  peristaltic  unrest  and 
pain  (spasmodic)  preceding  vomiting;  long  history;  periods  of  improvement; 
hyperacidity  usual;  sarcinae  present  in  number;  emaciation,  but  no 
cachexia;  vomiting  of  large  amount;  usually  no  tumor,  and  if  present 
very  small  and  smooth  on  palpation;  frequently  history  of  previous  ulcer; 
usually  no  blood,  as  ulcer  is  practically  healed,  or  contracting;  anemia 
present;  no  leukocytosis. 

Malignant  Stenosis. — Dilatation  of  stomach;  peristaltic  unrest;  short 
history;  no  period  of  improvement;  rapid  loss  of  weight;  pain  continuous; 
cachexia;  little  or  no  free  hydrochloric  acid;  lactic  acid  present;  Boas- 
Oppler  bacilli;  vomiting  large  amount  and  often,  odorous;  at  time  coffee- 
grounds  in  vomit  from  ulceration  of  growth;  anemia  marked;  leukocytosis. 

Chronic  Gastritis. — ^Long  history  of  dyspepsia;  absence  of  cachexia; 
no  lactic  acid;  less  anemia;  no  leukocytosis;  intense  pain  absent,  more 
feeling  of  discomfort;  no  real  pain  on  palpation;  mucus  in  gastric  contents, 
HCl  diminished  or  absent. 

With  nephritis  and  loss  of  cardiac  compensation  with  gall-bladder  dis- 
ease or  chronic  appendicitis,  or  with  arteriosclerosis,  especially  the  visceral 
type,  there  may  also  be  marked  deficiency  or  even  absence  of  free  hydrochloric 
acid,  and  these  conditions  must  be  held  in  consideration  for  the. purpose 
of  differential  diagnosis. 

Achylia  Gastrica. — Total  acidity  much  lower  than  in  cancer,  from 
4-j-  to  2-1-  or  less;  free  hydrochloric  acid,  pepsin  and  rennet  absent; 
no  mucus;  scarcely  any  gastric  juice;  food  particles  coarse  and  nearly 
dry;  course  long;  no  cachexia;  no  lactic  acid;  may  be  considerable  loss  of 
weight.     In  transitional  stage  (commencing)  some  claim  mucus  is  present. 

Moreover,  with  pernicious  anemia,  we  have  achylia  gastrica,  but 
often  other  symptoms  suggestive  of  carcinoma  of  the  stomach,  namely, 
pallor,  weakness,  loss  of  appetite,  perhaps  severe  vomiting,  even  ac- 
companied by  blood,  gas,  and  distress  after  eating.  Examination  of  the 
blood  shows  the  findings  of  pernicious  anemia. 

Nervous  Gastralgia. — Patient  nervous  or  hysteric;  pain  irregular  or 
relieved  by  pressure;  free  intervals  from  pain;  appetite  variable;  no 
regularity  of  vomiting;  secretory  function  is  variable;  no  tumor;  no 
cachexia;  character  of  food  makes  little  difference  as  to  symptoms. 

Carcinoma  of  the  gall-bladder  is  found  in  the  location  of  gall-bladder; 
follows  respiratory  movements  of  the  liver;  shows  no  lateral  motility 
and  does  not  allow  expiratory  fixation.  Its  position  is  unchanged  if 
the  stomach  is  inflated  with  air.  It  rarely  causes  dilatation  of  the  stom- 
ach unless  adhesions  form ;  and  dyspeptic  disturbances  are  not  marked,  as 
a  rule.     Jaundice  may  be  present.     Head's  zone  is  present. 

Enlarged  lymph-glands  can  hardly  be  mistaken,  as  there  is  the  absence 


350  DISEASES  OF  THE   STOMACH  AND  INTESTINES 

of  gastric  symptoms;  no  gastric  findings,  as  in  carcinoma  of  the  stomach; 
and  radiography  of  the  latter  organ  enables  a  differentiation. 

Growths  of  the  peritoneum  or  mesentery  are  more  diffuse  and  rarely 
movable  on  respiration,  and  radiography  of  the  stomach  and  the  symp- 
toms enable  one  to  differentiate.  One  must  remember  that  cancer  of 
other  organs  at  times  shows  gastric  findings  of  cancer  of  the  stomach. 

Exudates  or  adhesions  give  none  of  the  symptoms,  gastric  findings  or 
rontgenographs  of  carcinoma. 

Duration  of  Carcinoma  of  the  Stomach.— Osier  reports  15  cases 
with  fatality  under  three  months;  45,  under  a  year;  4  cases,  two  years  or 
over;  i  case,  two  and  a  half  years.  The  general  average  is  about  a  year 
to  a  year  and  a  half. 

Cases  involving  the  cardia  or  the  pylorus  are  more  rapid,  as  sub- 
nitrition  occurs  more  quickly.  The  medullary  type  is  more  quickly  fatal. 
Complications  shorten  the  disease. 

It  is  interesting  to  learn,  however,  that  some  cases  of  inoperable 
carcinoma  of  the  stomach  improve  greatly  after  palliative  gastro-enter- 
ostomy.  Eleven  such  cases  have  been  collected  from  Czerny's^  clinic, 
in  which  the  patients  were  well  from  two  to  fourteen  years  later. 

Prognosis.— This  has  been  considered  fatal,  though  recent  results 
are  more  favorable.  Surgery  has  relieved  conditions  temporarily  and 
prolonged  life,  while  medical  treatment  has  failed,  though  it  has  helped 
to  alleviate  suffering. 

Kocher  has  reported  one  case  in  which  the  patient  was  in  good  health 
five  and  a  half  years  after  resection  of  the  pylorus  for  carcinoma;  and 
Wolfler  one  in  which  the  patient  was  well  for  five  years  when  a  metastasis 
occurred. 

Recently  cases  of  apparent  cure  have  been  reported.  In  an  analysis 
of  the  results  of  operative  treatment  of  gastric  cancer  at  Braun's  Clinic  at 
Gottingen,  Creite^  refers  to  one  case  in  which  fourteen  years  after  resec- 
tion of  the  pylorus  for  carcinoma  the  patient  was  in  perfect  health. 

Lately,  more  favorable  results  have  been  reported.  Leriche^  has  col- 
lected records  of  89  patients  on  whom  gastrectomy  was  performed,  found 
in  good  health  three  years  after  operation;  and  of  these  34  no  less  than 
five  to  ten  years  after  operation. 

Out  of  79  cases  treated  b}'^  gastrectomy,  Patterson"*  collected  33 
(41.6  per  cent.)  who  were  free  from  recurrence  three  years  or  more  after 
operation. 

Deaver  shows  that  we  may  expect  10  to  15  per  cent,  to  be  cured 
by  radical  operation. 

According  to  Kausch,^  Makkas  traced  92  of  Mikulicz's  patients 
operated  on  before  1902,  and  found  17,  or  14.3  per  cent.,  well  more  than 
three  years  after  operation.  The  Mayos  have  secured  good  results. 
Further  statistics  are  unnecessary.  The  radical  operation,  gastrectomy, 
evidently  affords  results  in  some  cases. 

1  Wells,  Resistance  to  Cancer,  Jour.  Amer.  Med.  Assoc.,  May  29,  1909. 

2  Jour.  Amer.  Med.  Assoc,  Aug.  24,  1907,  p.  273. 
'  Revue  de  Medecin,  Jan.,  1907. 

*Intemat.  Med.  Annual,  1908,  p.  537. 
«Ibid. 


CANCER   OF   THF   STOMACH    (CARCINOMA  VENTRICULl)  351 

• 

Schlatter  reported  in  1897  the  first  successful  case  of  total  extir- 
pation of  the  stomach,  with  survival  of  the  patient  for  a  considerable 
period.  Bernays,  of  St.  Louis,  and  others  have  reported  the  survival 
of  cases  for  some  time  after  operation.  The  operation  has  been  generally 
abandoned  and  we  find  that  the  so-called  gastrectomies  are  generally  not 
complete  removal. 

Treatment. — There  are  two  methods  of  treatment,  surgical  and 
medical,  of  which  the  only  hope  of  cure  lies  in  the  former,  medical  treat- 
ment being  only  justifiable  if  the  case  is  inoperable,  or  refuses  operation, 
or  as  an  adjunct  to  palliative  operation. 

Surgery. — ^Before  referring  to  the  radical  or  palliative  methods  in 
surgery,  I  desire  to  call  to  my  readers'  attention  the  necessity  of  the 
education,  not  so  much  of  the  patient,  who  will  generally  consent,  if  the 
matter  is  placed  fairly  before  him,  but  of  the  physician  and  the  specialist 
in  gastric  diseases,  as  to  the  value  of  early  exploratory  laparotomy  for  the 
purpose  of  diagnosis. 

William  Mayo^  justly  remarks  that  in  an  early  exploratory  incision 
we  have  the  one  diagnostic  resource  which  is  reliable,  and  which  must 
be  resorted  to  in  a  large  majority  of  cases  before  a  surgical  diagnosis 
can  be  made,  and  without  it  the  truth  is  but  slowly  established  at  the 
expense  of  progressive  hopeless  involvement.  It  can  be  safely  accom- 
plished through  a  small  incision.  He  further  calls  to  our  attention  that 
the  chemic  findings  of  the  gastric  secretion  gain  in  diagnostic  importance 
with  the  progress  of  the  disease  and  become  of  the  greatest  value  when  the 
patient  is  in  a  hopeless  condition,  and  that  exploration  should  not  be  de- 
layed by  reason  of  the  inconclusive  nature  of  the  results.  He  has  further 
demonstrated  that  about  60  per  cent,  of  cases  of  cancer  begin  in  the  pylorus 
and  70  per  cent,  in  the  pyloric  region,  and  that  the  early  diagnosis  of 
cancer  depends  in  a  great  measure  upon  the  introduction  of  the  mechanic 
phenomena  from  obstruction  at  the  pylorus.  It  is  the  interference  with 
gastric  motility  which  first  calls  the  patient's  attention  to  his  trouble  and 
not  the  presence  of  the  cancer  itself.  Moreover,  a  case  with  marked 
symptoms  of  cancer  of  the  stomach,  but  without  any  evidence  of  pyloric 
obstruction,  proves,  on  exploration,  to  be  the  victim  of  advanced  and 
hopeless  disease  of  the  body  of  the  organ,  in  which  there  were  no  symp- 
toms during  the  operable  period.  The  presence  of  a  tumor  does  not 
demonstrate  inoperability,  as  a  small  movable  tumor  in  the  pyloric  region 
may  be  a  favorable  indication.  Limitation  to  the  pyloric  end  and  mobility 
are  the  important  factors,  also  the  degree  of  lymphatic  infection. 

Pyloric  Stenosis  is  a  Surgical  Disease  Whether  it  is  Benign  or  Malig- 
nant.-— It  seems,  therefore,  especially  sound  doctrine  in  all  cases  with 
symptoms  pointing  to  pyloric  stenosis  to  perform  exploratory  laparotomy 
to  settle  the  type  of  stenosis  and  immediately  further  operation,  of 
greater  or  lesser  extent,  the  character  depending  on  the  cause  of  obstruc- 
tion. This  rule,  the  author  believes,  should  be  followed  out,  whether  the 
patient  be  over  forty  years  of  age  or  not.  Pyloric  stenosis,  in  any  event, 
is  a  surgical  condition. 

'  Ann.  of  Surg.,  March,  1904. 


352 


DISEASES   OF  THE   STOMACH  AND  INTESTINES 


W.  L.  Rodman^  also  advances  numerous  legitimate  reasons  for  ex- 
ploratory laparotomy.  Parker  Syms^  refers  to  the  necessity  of  opera- 
tion in  chronic  gastric  ulcer,  in  the  precancerous  stage,  and  also  to  the  value 
of  exploratory  laparotomy  in  all  doubtful  cases  to  settle  the  diagnosis. 
Rodman  holds  that  rapid  emaciation  with  gastric  symptoms  in  a  person 
over  forty  years  of  age  almost  invariably  calls  for  an  exploratory  laparotomy. 
Deaver^  advocates  early  exploratory  laparotomy  and  believes  that  the 
stomach  should  also  be  opened. 

In  elderly  persons,  whether  previously  in  good  health  or  not,  with 


Fig.  197. — The  lymphatics  of  the  stomach  (Moynihan,  after  Cun6o). 

gastric  symptoms,  anemia,  and  rapidly  developing  emaciation,  after  frequent 
examinations,  both  of  the  patient  and  gastric  contents  for  several  weeks, 
even  if  no  definite  results  are  secured  by  analysis  and  no  tumor  be  de- 
tectable, exploratory  laparotomy  is  indicated.  This  is  true  whether  symp- 
toms of  stenosis  are  present  or  not.  When  possible  the  x-rays  should  he 
employed  _to  confirm  the  fact  that  it  is  a  surgical  condition.  If  such  examina- 
tion were  impossible,  I  would  even  so  advocate  exploration  when  the  above 
symptoms  were  noted.  Some  patients,  of  course,  will  not  consent  to  any 
operation  until  even  palliative  operative  procedure  is  too  late. 

1  Jour.  Amer.  Med.  Assoc,  Jan.  18,  1908,  pp.  165-169. 
*  N.  Y.  Med.  Jour.,  July  16,  19 10. 
'N.  Y.  Med.  Jour.,  July  3,  1915. 


CANCER   OF  THE   STOMACH    (CARCINOMA  VENTRICULl)  353 

I  have  seen  a  number  of  abdomens  opened  and  immediately  closed  as 
inoperable,  in  one  case  notably  the  entire  stomach-wall  being  infiltrated. 
If  the  medical  profession  would  recognize  the  value  of  exploratory  incision, 
I  believe  many  lives  could  he  saved. 

Radical  Operation. — Billroth,  in  1878,  was  the  first  to  prove  the  pos- 
sibility of  resection  of  the  pylorus  for  cancer,  but  it  has  been  clearly  demon- 
strated that  this  operation  is  insufiicient.  Mikulicz  has  pointed  out  that 
on  the  lesser  curvature  the  blood  and  lymph-vessels  lie  in  the  wall  of  the 


Fig.  198. — W.  J.  Mayo's  method  of  partial  gastrectomy  for  cancer  of  the  stomach. 
Ligation  of  gastrohepatic  omentum  and  superior  vessels  in  such  manner  as  to  leave  all 
the  lymph-nodes  attached  to  the  part  of  the  stomach  to  be  excised;  also  lines  of  division 
of  duodenum  and  stomach:  a,  Mikulicz-Hartmann's  line  (Fowler). 


stomach  itself,  and  that  it  is  necessary  in  every  case  of  pyloric  cancer  to 
remove  all  the  lesser  curvature  to  the  gastric  artery.  Cuneo  has  demon- 
strated that  there  are  but  few  lymph-glands  along  the  greater  curvature 
and  that  these  are  chiefly  confined  to  the  pyloric  region. 

One  must  remember  in  operating  that  carcinomatous  emboli  in  the 
early  stages  do  not  necessarily  involve  glands  one  after  another,  but  may 
primarily  pass  into  glands  at  a  considerable  distance. 

The  illustrations  (Figs.  197-199)  demonstrate  the  glandular  relations, 
the  correct  line  of  incision,  and  the  completed  operation. 
2.? 


354 


DISEASES   OF  THE   STOMACH  AND  INTESTINES 


In  all  cases  of  pyloric  cancer  a  partial  gastrectomy  and  pylorectomy 
should  be  performed.  If  cancerous  metastases  or  marked  adhesions  are 
present,  radical  operation  is  contraindicated,  as  it  is  in  the  case  of  extreme 
debility  or  old  age. 

C.  H.  and  W.  J.  Mayo's  latest  statistics  for  this  operation,  from  April, 
1897,  to  January  27,  1910,  are  34  deaths  out  of  266  operations,  and  show 
12.4  per  cent,  mortality,  and  Deaver's,  11. 11  per  cent.     The  latter  has 


Fig.  199. — W.  J.  Mayo's  method  of  partial  gastrectomy  for  cancer  of  the  stomach. 
Operation  completed  (Fowler). 


tabulated  393  cases  by  various  operators,  with  an  average  26.5  per  cent, 
fatality. 

Out  of  the  Mayos'^  266  operations,  42  were  for  benign  tumors  or  ulcers, 
or  where  the  diagnosis  was  not  microscopically  established.  They  are, 
therefore,  excluded  from  the  following  statistics. 

Table  i. — Operations  for  carcinoma  involving  the  pyloric  end  of  the 
stomach: 

Total  number 224 

Males 163 

Females 61 

Age  of  oldest 81 

Age  of  youngest 3° 

Average  age SS 

*  Partial  Gastrectomy  (Mayo),  Jour.  Amer.  Med.  Assoc.,  May  14,  1910. 


CANCER  OF  THE   STOMACH   (CARCINOMA  VENTRICULl)  355 

Table  2. — Patients  operated  on  over  five  years  ago: 

Total  number 50 

Present  condition  known 39 

Alive  and  well  (i,  eight  years  two  and  a  half  months;  i,  eight  years;* 

I,  seven  years  two  months;  i,  six  years  eleven  months;  i,  six  years; 

I,  five  years  three  and  a  half  months;  i,  five  years) — 6  still  alive 

and  well. 

Table  3. — Patients  operated  on  over  four  years  ago: 

Total  number 85 

Present  condition  known 64 

Alive  and  well 13 

Table  4. — Patients  operated  on  over  three  years  ago: 

Total  number 117 

Present  condition  known 88 

Alive  and  well 18 

There  are  107  patients  operated  on  less  than  three  years  ago,  too  recent 
for  statistical  value.  The  Mayos  advocate  partial  gastrectomy  with 
pylorectomy  when  possible. 

Palliative  Operation. — This  should  be  performed  when  radical  opera- 
tion cannot  be  carried  out,  to  prevent  death  from  starvation  and  to  re- 
move the  irritating  effect  of  food,  with  the  resulting  pain.  The  operations 
are: 

(a)  Gastrostomy  is  the  formation  of  a  fistulous  opening  into  the  stomach; 
indicated  in  cancerous  stenosis  of  the  cardia,  with  rapid  loss  of  weight  and 
severe  pain. 

(b)  G  astro-enter  ostomy  is  an  anastomosis  between  the  stomach  and 
small  intestine  (jejunum),  in  cancer  of  the  pylorus  with  stenosis;  for 
similar  reasons. 

These  operations  prolong  life  and  give  the  patient  considerable  com- 
fort, and  there  is  often  temporary  increase  in  weight.  They  are  less 
severe  than  the  radical  operations,  and  are  only  contraindicated  in  ex- 
treme debility  or  great  age,  with  the  patient  in  such  condition  that  fatality 
would  be  assured.  Gastrostomy  can  be  performed  under  cocain  (local) 
anesthesia  if  necessary,  I  have  already  referred  to  the  fact  that  in  11  of 
Czerny's  cases  the  patients  were  living  from  three  to  fourteen  years  after 
gastro-enterostomy. 

Medical  Treatment. — Diet. — The  first  important  feature  is  the  en- 
deavor to  relieve  the  condition  of  subnutrition  and  to  give  the  patient 
food  which  he  will  most  easily  assimilate.  If  there  is  stricture  of  the 
pylorus  or  esophagus,  it  will  necessitate  the  use  of  liquid  food  entirely, 
or  mushes  in  addition,  if  there  is  less  severe  obstruction. 

If  the  cancer  involve  the  body  of  the  stomach  alone,  food  of  more  solid 
character  can  be  taken,  as  the  motor  functions  are  not  as  greatly  inter- 
fered with.  In  the  dietary  we  include  milk,  koumiss,  matzoon,  bacillac, 
farinaceous  food ;  soups,  with  finely  divided  vegetables,  such  as  pea,  bean, 
and  potato;  purees,  broths,  gruels,  bouillon;  raw  or  soft-boiled  eggs;  butter 
plenty,  tea,  weak  coffee,  and  cream;  crackers  softened  in  water  and  milk- 
toast. 

*  One  has  died  of  recurrence. 


356  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

In  some  cases,  chicken,  squab,  scraped  meat,  sweetbread,  stale  bread, 
oysters,  fish,  etc.  Somatose,  Wyeth's  beef-juice,  Mosquera's  beef-jelly, 
soluble  beef  peptonoids.  Armour's  extract  of  beef,  tropon,  and  rare  beef- 
juice,  are  useful  as  adjuncts. 

I  have  employed  as  many  as  eight  raw  eggs  a  day  beaten  up  in  milk,  in 
addition  to  other  foods.  They  possess  great  nutritive  value.  Russell's 
emulsion  of  mixed  fats  is  of  service.  Food  should  be  administered  in 
divided  small  meals,  five  to  eight  a  day.  The  calorie  value  can  be  esti- 
mated, but  the  chief  criterion  is  their  digestibility  and  the  increase  in  the 
patient's  weight,  which  should  be  carefully  recorded.  Temporary  increase 
in  weight  can  often  be  secured. 

It  is  quite  remarkable  what  results  one  can  secure  by  proper  methods 
of  feeding.  One  case  who  had  lost  70  pounds  in  weight,  the  weight  on 
admission  to  the  Red  Cross  Hospital  being  only  1 20  pounds,  was  vomiting 
all  food,  emesis  occurring  seven  or  eight  times  daily.  The  patient's  pulse 
was  hardly  detectable,  and  he  was  so  feeble  that  he  could  only  walk  when 
supported.  There  was  a  marked  growth  at  the  pylorus,  and  the  lower 
border  of  the  stomach  lay  three  finger-breadths  below  the  umbilicus. 
Though  palliative  gastro-enterostomy  was  indicated,  the  writer  believed 
that  the  patient's  physical  condition  precluded  an  immediate  operation, 
and  in  this  opinion  the  surgeons  concurred.  Lavage  twice  daily  was  im- 
mediately begun,  the  patient  being  fed  on  each  occasion  through  the 
stomach-tube,  with  additional  feedings,  and  nutritive  enemata.  For  ex- 
ample, I  quart  (liter)  of  peptonized  milk,  six  to  eight  raw  eggs,  iron  tropon, 
3  drams,  were  given  in  divided  doses  by  mouth,  with  the  addition  of  broths 
and  strained  gruels — an  extra  pint  in  divided  doses.  Butter  was  added 
to  these,  and  later  crackers  crumbled  in  the  broths  and  thicker  gruels. 
Four  nutritive  enemata,  each  containing  3  ounces  of  peptonized  milk  and 
one  raw  egg,  were  given  daily.  Rose's  belt  was  applied  to  elevate  the  stom- 
ach, and  after  each  feeding  the  patient  was  turned  on  his  right  side  and 
kept  in  this  position  for  half  an  hour  to  facilitate  emptying  the  stomach. 
Olive  oil,  2  ounces,  were  given,  a.  m.  and  p.  m.,  to  facilitate  the  passage  of 
food  through  the  pylorus  and  also  aid  nutrition,  and  belladonna  tincture, 
10  minims  t.i.d.,  to  relax  spasm.  Vomiting  only  occurred  twice  after 
treatment  was  begun.  The  patient  gained  20  pounds  in  eight  weeks 
and  then  underwent  a  successful  gastro-enterostomy,  living  a  year  in 
comfort. 

X-rays. — There  have  been  various  claims  made  for  the  value  of  the 
x-ray  in  the  treatment  of  internal  cancer,  such  as  of  the  stomach  or  intes- 
tines, that  it  diminishes  the  size  of  the  growth  and  relieves  pain.  Pfahler^ 
claims  cures  in  some  cases  of  deep-seated  abdominal  carcinomata  by  the 
.T-rays,  employing  filtration  and  cross-firing.  I  have  seen  cases  in  which 
the  pain  seemed  to  be  somewhat  relieved,  but  never  any  permanent  re- 
sults. In  the  treatment  of  skin  cancer  definite  or  even  curative  results 
have  been  secured.  Beck's  eventration  treatment  with  employment  of 
the  x-rays  is  described  at  the  end  of  the  chapter  and  might  be  palliative., 
Incidentally  Morton  has  recommended  the  use  of  fluorescent  media 
internally  in  connection  with  the  x-rays,  but  Henry  Piffard  and  S.  Tousey 
^Journal  A.  M.  A.,  May  i,  1915. 


CANCER   OF   THE    STOMACH    (CARCINOMA  VENTRICULl)  357 

have  conclusively  exploded  his  theory  and  shown  that  fluorescence  does 
not  occur.     Direct  light  rays  are  necessary. 

The  first  researches  with  the  internal  administration  and  dosage  of 
fluorescein  were  reported  by  me  in  connection  with  gastrodiaphany.^ 

Radium. — The  radium  treatment  for  cancer  of  the  stomach  and  esoph- 
agus was  first  introduced  by  Einhorn.^  He  first  employed  for  the  stomach 
a  hard-rubber  capsule  that  can  be  unscrewed  and  which  contains  a  glass 
radium  flask  (Curie  20,000  strength).  To  the  rubber  capsule  is  attached 
a  silk  thread,  in  which  several  knots  are  tied,  indicating  the  distance  from 
the  lips  to  the  cardia  and  how  far  the  capsule  lies  from  the  cardia.  The 
capsule  is  introduced  like  his  stomach-bucket.  One  type  of  improved 
instrument,  depicted  in  Fig.  200,  has  in  addition  a  small  canal  at  the  mar- 
gin of  the  capsule,  which  can  be  threaded  on  a  guide.  A  duodenal  bucket 
with  thread  is  swallowed  and  the  capsule  is  later  passed  along  the  thread 
to  the  pylorus.     His  radium  introducer  consists  of  a  flexible  introducer  and 


^fi^^d 


Fig.  200.- 


-A,  Radium  introducer;  B,  radium  receptacle  for  stomach  and  esophagus, 
with  whalebone  stem. 


mandril,  which  are  withdrawn  after  placing  the  capsule  in  the  desired 
position. 

Serious  burns  have  resulted  from  prolonged  exposure  to  radium,  and 
no  definite  results  are  yet  reported.  I  would,  therefore,  not  recommend  the 
method. 

An  instrument  that  is  connected  to  a  thin  rubber  tube  in  which  a 
mandrin  is  slipped  for  the  purpose  of  introduction,  and  then  the  latter 
removed,  has  been  devised  by  Einhorn  for  the  treatment  of  malignant 
esophageal  stricture,  but  his  most  recent  instruments  are  depicted  in  Fig. 
200, 

He  recommends  leaving  it  in  the  esophagus  from  half  an  hour  to  an 
hour,  and  claims  an  increase  in  the  permeability  of  the  stricture,  less  pain, 
and  increased  ability  in  swallowing.  As  in  this  case  the  radium  can  be 
directly  applied  and  some  definite  results  have  been  secured,  the  method 
might  be  of  value.  The  radium  introducer  is  the  best  instrument.  The 
question  of  damage  from  overexposure  must  be  carefully  considered.  One 
case  reported,  of  six  hours'  exposure,  the  writer  believes  highly  dangerous. 

*  Med.  News,  April  10,  1904. 
^  Med.  Rec,  March  5,  1904. 


358  DISEASES   OF  THE  STOMACH   AND  INTESTINES 

The  method  is  evidently  worthy  of  further  investigation.  It  is  only  applic- 
able to  patients  refusing  operation. 

Drugs. — Sodium  lodid. — In  stricture  of  the  cardia,  Boas  has  recom- 
mended sodium  iodid,  30  to  45  grains  (2.0-3.0  grams),  in  divided  doses 
during  the  day,  and  claims  that  during  a  treatment  of  over  six  months 
the  patient  gained  a  little  in  weight  and  was  relieved  from  some  of  the 
symptoms.  Though  transient  improvement  occurs,  it  is  worthy  of  trial 
if  it  adds  to  the  patient's  comfort. 

Thiosinamin.- — Sachs^  claims  to  have  been  successful  with  thiosinamin 
by  hypodermic  use  in  the  treatment  of  two  cases  of  pyloric  stricture;  and 
MichaeUs^  found  it  softened  an  esophageal  stricture  and  enabled  him  to 
dilate  it  with  bougies. 

Thiosinamin  (fibrolysin)  is  moderately  soluble  in  water,  soluble  in  3 
parts  of  alcohol,  and  readily  soluble  in  ether.  Hypodermic  injection  of 
fibrolysin  can  be  given  in  15  per  cent,  alcoholic,  or  10  per  cent,  glycerin, 
solution. 

The  average  dose  is  3^  to  iH  grains  (0.032-0.1  gram).  Einhorn 
advises  its  use  by  mouth. 

It  is  worthy  of  trial  in  stenosis  of  the  esophagus  or  pylorus  when  opera- 
tion is  refused.     The  following  is  useful: 

I^.  Thiosinamin 0.5  (7^  gr.); 

Glycerini 6.0  ( 5  iss) ; 

Sjnrup,  cort.  aurant 20.0  ( 3  v) ; 

Aq.  destil q.  s.  ad.  60.0  (5ij). — M. 

Sig. — Teaspoonful  in  water  t.i.d. 

Arsenic  has  been  recommended,  Fowler's  solution,  3  to  5  drops 
(0.2-0.3)  daily;  or  sodium  arsenate,  Ho  to  ^'^5  grain  (0.002-0.0026)  t.i.d., 
but  their  chief  value  is  combined  with  iron,  such  asBlaud's  pill,  iron  tropon, 
to  combat  the  anemia. 

I^.  Blaud's  iron  pill  (fresh) gr.  v  (0.32); 

Sod.  arsen gr.  J^o  (0.0013). — M. 

One  pill,  made  soft  with  honey,  is  an  excellent  combination,  given  t.i.d. 

Condnrango  was  first  recommended  by  Friedreich  in  1874  for  the  treat- 
ment of  cancer,  but  it  has  no  specific  action. 

Alone  or  combined  with  dilute  hydrochloric  acid  (suggested  by  Ewald), 
it  is  an  excellent  stomachic  to  improve  the  appetite,  and  at  times  increase 
of  weight  may  result. 

It  may  be  given  as  the  fluidextract  of  condurango,  15  to  20  drops 
(1.0-1.3)  in  water  t.i.d.,  with,  or  without  dilute  hydrochloric  acid,  half  an 
hour  before  meals;  or  the  decoction  of  condurango  may  be  employed: 

I^.  Decoct,  condurango 20.0  to    25.0  gram.; 

Water 200.0  to  250.0  c.c. — M. 

Tablespoonful  t.i.d.  before  meals. 
Other  stomachics,  such  as  are  advised  in  chronic  gastritis,  are  of 
service: 

1  Ther.  d.  Gegenw.,  1907,  No.  1. 
*  Med.  Klin.,  1907,  No.  10. 


CANCER  OF  THE  STOMACH   (CARCINOMA  VENTRICUU)  359 

I^.  Acidi  hydroch.,  dilute 3 ij  (8.0) ; 

Tr.  nuc.  vomic 3ij  (g.o) ; 

Comp.  tinct.  cinchona 5ss  (16.0); 

Aq.  destil q.  s.  5iv  (125.0).— M. 

Dose,  one  to  two  teaspoonfuls  in  water  t.i.d.  before  meals. 

Methylene-blue. — Einhorn*  has  employed  methylene-blue  in  capsules 
once  or  twice  daily  for  some  years  past — 3  grains  (0.2  grams).  He 
believes  it  exercises  a  beneficial  action  in  some  cases. 

A.  Jacobi^  advocated  its  use  in  inoperable  intra-abdominal  cancer, 
for  about  fifteen  years  and  claims  mitigation  of  symptoms,  prolongation  of 
life  for  some  years  in  several  cases,  and  a  temporary  retrogression  of  the 
tumor.  He  has  not  cured  a  case.  He  believes  that  exposure  to  sunlight 
is  an  aid,  as  methylene-blue  is  fluorescent. 

He  advocates  doses  (divided),  commencing  at  2  grains  a  day  and 
increasing  to  6  grains,  combining  belladonna,  and  suggests  the  following: 

I^.  Methylene-blue :  gr.  vj  (0.4); 

Ext.  belladonna gr.  M  (0-048); 

Arson,  acid gr.  >^o  (0.0065). — M. 

Divide  into  four  pills. 

Sig. — One  t.i.d.  after  eating  and  at  bedtime. 

Methylene-blue  treatment  may  be  tried  in  inoperable  cases  as  a 
palliative. 

Trypsin  Treatment. — For  the  theory  of  Beard,  on  which  he  bases  his  so- 
called  trypsin  treatment,  I  refer  my  readers  to  his  various  articles.  The 
author  has  tried  it  out  and  found  it  useless. 

Wm.  S.  Bainbridge^  demonstrated  a  reported  cure  by  Morton  to  be 
an  absolute  failure. 

He  has  had  under  observation  about  100  cases  undergoing  this  method 
of  treatment,  which  are  reported  in  the  Medical  Record  of  July  17,  1909. 
He  found  the  method  a  failure. 

Autolysin. — There  have  been  numerous  reports  as  to  the  use  of  this 
remedy  advocated  by  S.  P.  Beebe,^  apparent  cures  being  reported  after  a 
short  period  of  treatment.  Such  statements  are  of  no  value  as  to  ultimate 
results,  since  a  period  of  several  years  should  elapse  without  recurrence. 
The  writer  is  a  sceptic  regarding  such  cancer  cures. 

Injections  of  Cancer  Residue,  Cancer  Vaccine  and  Anticancer  Globulins. 
—J.  Walter  Vaughan,  at  the  annual  meeting  of  the  Michigan  State  Med- 
ical Society,"  Sept.  28-29,  1910,  described  his  experiences  with  injecting 
the  non-toxic  protein  of  the  cancer  cell,  or  cancer  residue,  in  the  endeavor 
to  find  proof  with  regard  to  the  formation  of  a  specific  ferment  by  means  of 
a  study  of  the  various  blood  elements,  particularly  the  leukocytes.  Vaug- 
han experimented  on  12  persons  suffering  from  malignant  growth. 
The  serum  from  sheep  and  rabbits  was  employed,  after  sensitization  to 
cancer  protein,  in  cases  of  human  carcinoma  and  sarcoma.     Abderhalden 

*  Deutsch.  med.  Wochenschr.,  1891,  No.  18. 

*  Jour.  Amer.  Med.  Assoc,  Nov.  10,  1906. 
'  N.  Y.  Med.  Jour.,  March  2,  1907. 

*N.  Y.  Med.  Jour.,  May  15,  1915,  also  ibid,  Nov.  13,  1915  (Williams). 

*  Jour,  of  Michigan  State  Med.  Soc;  also  N.  Y.  Med.  Jour.,  Oct.   15,  1910. 


360  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

has  reported  favorably  on  the  use  of  such  serum  in  rat  sarcoma.^  There 
was  some  improvement  in  Vaughan's  cases,  but  acute  nephritis  developed 
in  several  cases  following  use  of  the  serum,  so  it  was  given  up.  An  attempt 
was  then  made  to  obtain  the  specific  ferment  free  from  objectionable  serum 
proteins.  This  was  successful  and  the  product  has  been  named  anticancer 
globulins.  In  a  series  of  100  cases,^  vaccines  (cancer  cell  vaccines  and 
cancer  residue)  and  ferments  (globulins  and  leukocyte  extracts)  were 
apparently  successful  in  some  cases,  there  being  no  recurrences  so  far.  It 
is  interesting  to  note  that  50  of  the  patients  were  classed  as  inoperable 
either  primarily  so,  or  having  such  severe  recurrences  that  a  second  opera- 
tion could  not  be  performed. 

The  study  of  blood  counts  in  these  cases  leads  to  the  conclusion  that 
those  in  which  the  percentage  of  large  mononuclear  leukocytes  increases  to 
from  10  to  20  per  cent,  following  specific  treatment,  do  well;  while  those 
running  a  high  polymorphonuclear  count  and  in  which  the  percentage  of 
large  monunuclear  cells  is  not  materially  increased,  receive  no  benefit. 
The  field  of  either  vaccine  or  residue  is  limited,  and  the  best  results  are 
obtained  in  which  the  amount  of  tumor  tissue  is  small  and  in  which  the 
differential  leukocyte  count  shows  a  decided  reaction  following  the  admin- 
istration of  the  cancer  protein.  Vaughan  uses  the  globulins  intravenously 
and  the  cancer  residue  intraperitoneally. 

The  vaccine  (or  residue)  is  efficient  only  in  those  cases  which  respond 
with  a  considerable  increase  in  the  percentage  of  large  mononuclear  leuko- 
cytes. It  is  advocated  to  employ  it  chiefly  in  operable  cases  in  which  a 
single  intraperitoneal  dose  is  given  twenty-four  hours  before  operation,  that 
the  blood-stream  may  have  some  specific  ferment  available  for  splitting 
up  the  malignant  cells  not  removed,  or  such  that  enter  the  blood  or  lymph- 
channels  through  manipulation  at  operation.  The  ferment  (globulin) 
seems  to  be  beneficial  for  the  first  three  or  four  doses.  Its  active  period 
is  about  ten  days  and  subsequent  injections  seem  to  cause  little  reaction. 

A  series  of  cases  therefore  have  been  treated  by  employing  two  to  five 
doses  of  ferment  (globulin)  followed  by  two  injections  of  residue.  Clinic- 
ally this  gave  better  results  in  the  advanced  inoperable  cases.  The  dose 
of  globulins  advised  is  50  to  100  mg.  by  the  intravenous  method.  Vaughan 
concludes  that  he  does  not  believe  any  method  of  specific  therapy  will  be  of 
much  avail  when  there  are  large  amounts  of  malignant  tissue  present.  Large 
amounts  of  globulins  200  to  300  mg.  may  prove  fatal  moreover  in  these 
cases.  He  believes  the  real  value  of  either  vaccine  or  ferment  is  in  their  use 
in  connection  with  operative  removal  in  order  to  destroy  such  cells  as  are  not 
removed  by  operation  and  thus  reduce  the  percentage  of  recurrences. 

He  advocates  an  intraperitoneal  injection  of  residue  twenty-four  hours 
before  operation.  If  the  increase  in  large  mononuclear  leukocytes  reaches 
15  to  25  per  cent,  before  operation,  this  is  deemed  sufficient.  If  this  does 
not  occur,  give  100  mg.  of  globulins  intravenously  following  operation. 
In  all  cases  alternate  vaccine  and  globulin  injections  were  given  frequently 
for  the  first  six  months  after  operation  and  then  once  a  month  thereafter. 
The  author  is  impressed  by  Vaughan's  conservatism  in  stating  that  some 

'  Med.  Klin.,  Berlin,  Feb.  9,  1914. 
2  Journal  A.  M.  A.,  Oct.  10,  1914. 


CANCER    OF  THE   STOMACH    (CARCINOMA  VENTRICULl)  361 

inoperable  cases  were  clinically  well  after  injection,  but  did  not  claim  a 
"cure,'"  and  also  his  statement  as  to  the  chief  value  of  this  method  in 
"  prevention  "  of  a  recurrence.     It  seems  worthy  of  trial. 

Treatment  of  Carcinoma  with  the  Body  Fluids  of  a  Recovered  Case. — 
The  late  E.  Hodenpyl^  reports  a  rare  case  of  recovery  from  extensive  car- 
cinoma with  residual  chyliform  ascites.  Injections  of  this  ascitic  fluid 
were  made  in  small  quantities  into  human  beings  in  cases  of  carcinoma  of 
various  types.  Hodenpyl  reported  that  in  all  cases  the  tumors  have 
grown  smaller,  in  some  they  have  disappeared  altogether,  in  others  there 
was  necrosis  of  the  tumor  tissue  with  the  subsequent  formation  of 
connective  tissue.  R.  Weil  investigated  the  "Properties  of  Ascitic  Fluids, 
Especially  in  Cases  of  Cancer,"^  among  his  experiments  employing  Hoden- 
pyl's  fluid.  The  results  were  almost  entirely  negative  in  character.  The 
writer  has  made  inquiries  as  to  the  results  of  the  injections  of  this  peri- 
toneal fluid  in  about  20  cases,  and  finds  that  though  in  some  there  was  tem- 
porary improvement,  ultimately  the  carcinomatous  condition  progressed. 
There  is  evidently  no  curative  value  in  the  method.  Risley's  conclusions 
from  his  experience  at  the  Massachusetts  General  Hospital  confirm  this 
view.^ 

Berkeley  and  Beebe  report  a  new  antiserum  for  cancer  and  claim^ 
temporary  improvement  in  some  cases. 

Lunckenbein  has  employed  the  intravenous  injection  of  cancer  extract^ 
of  the  mammary  gland  and  finds  the  outcome  apparently  the  same  whether 
the  patients  own  cancer  material  was  employed  or  that  from  another 
person.  He  claims  a  general  improvement  in  health  and  that  inoperable 
growths  have  retrogressed  until  they  could  be  successfully  removed. 

Cancer  Vaccine  {Neoformans). — This  has  been  recommended  for 
injection.  There  have  been  reports  of  temporary  improvement,  relief 
of  pain,  and  of  temporary  diminution  in  the  size  of  the  growth.  I  can 
find  no  authentic  record  of  cure  by  its  use. 

Doyen  first  advocated  the  method.  I  believe  it  useless  as  to  cure,  but 
it  has  apparently  been  of  temporary  assistance  in  some  cases  in  promoting 
the  comfort  of  the  patient,  in  inoperable  cases. 

Thyroid  Extract. — C.  G.  Am.  Ende^  reports  some  apparently  antitoxic 
properties  in  the  fluidextract  of  the  fresh  thyroid  gland  to  cancerous 
growth.     There  was  no  cancer  cure. 

Thymus. — F.  Gwyer^  reports  the  use  of  dried  and  powdered  thymus  of 
the  calf  in  doses  of  i  to  2  drams  (4.0-8.0)  three  or  four  times  a  day. 
He  claims  diminution  of  pain;  reduction  of  size  of  growth,  improved  diges- 
tion, and  diminution  or  arrest  of  the  growth.  Elimination  is  through  the 
secretory  organs,,  and  considerable  reaction  occurs,  so  it  cannot  be  used 
for  over  three  weeks.     I  would  not  advise  its  employment. 

Coley\s  fluid  (toxins  of  the  streptococcus  of  erysipelas  and  of  Bacillus 

'  Med.  Rec,  Feb.  26,  1910. 

*  Jour,  of  Med.  Res.,  vol.  xxiii,  No.  1  (New  Series,  vol.  xviii,  No.  i,  pp.  85-94, 
Aug.,  19 10). 

'  Jour.  Amer.  Med.  Assoc,  May  13,  191 1. 

*  Med.  Rec,  Mar.  16,  191 2. 

^  Miinch.  med.  Woch.,  May  12,  1914;  xli,  No.  19. 

*  A  Contribution  to  the  Treatment  of  Cancers,  Med.  Times,  Sept.,  1909. 

^  Ann.  of  Surg.,  July,  1907;  Ibid.,  April,  1908;  N.  Y.  Med.  Jour.,  Feb.  19,  1910. 


362  DISEASES   OF   THE   STOMACH  AND  INTESTINES 

prodigiosus)  might  be  tried,  though  the  results  have  been  more  favorable 
in  inoperable  sarcoma  and  rarely  in  carcinoma.  Coley  recommends  its 
use,  particularly  after  operation  for  carcinoma  to  lessen  the  chance  of  recur- 
rence.^ The  injection  should  be  begun  with  H  rninim  diluted  with  sterile 
water  to  ensure  accuracy  of  dosage,  given  by  hypodermic.  Daily  injections 
should  be  given,  increasing  by  \i  minim,  until  the  desired  reaction  and 
temperature  of  102°  to  io4°F.  has  been  obtained.  The  dose  should  then 
be  no  longer  increased  until  it  fails  to  give  a  reaction,  when  it  can  again  be 
increased  from  3^  to  }4  minim.  '  The  largest  dose  has  been  7  to  8  minims. 
Duration  of  treatment  from  six  weeks  to  four  to  six  months.  In  the  cases 
of  inoperable  sarcomata  from  30  to  80  injections  were  given.  The  best 
toxins  are  prepared  by  Tracy,  pathologist  to  the  Huntington  Cancer  Re- 
search Fund.     The  method  is  worth  trying  in  inoperable  carcinoma. 

Bier  has  reported  some  improvement  in  superficial  cancer  by  injection 
of  heterologous  blood  of  a  pig  (10  to  20  c.c.  at  a  dose);  and  Leyden  and 
Bergel  have  experimented  on  animals  suffering  from  cancer  with  the 
injection  of  liver  extracts,  but  these  methods  are  also  experimental. 

Treatment  of  Symptoms. —  Vomiting  and  Ectasia. — Systematic  lavage  is 
indicated  for  these  conditions  with  normal  saline  solution  or  milk  of 
magnesia,  i  to  2  ounces  (30.0-60.0)  to  the  quart  (liter)  of  water;  if 
marked  fermentation,  resorcin,  15  grains  (i.o),  can  be  added;  or  glyco- 
thymolin  or  listerin,  i  dram  to  i  pint  (4.0-500  c.c.)  of  water,  etc. 

Hemorrhage. — This  is  usually  not  severe.  Morphin,  3^  grain  (0.016), 
by  hypodermic;  the  ice-bag;  gelatin,  5  to  10  per  cent,  solution,  by  mouth, 
2  drams  to  K  ounce  (8.0-16.0),  every  one  to  two  hours  for  twelve  hours 
are  useful;  also  hypodermics  of  ernutin,  5  minims  (0.296  c.c),  or  ergot 
fluidextract,  and  the  methods  described  for  hemorrhage  under  Gastric 
Ulcer. 

Tremolihe's  Solution. — Gelatin  (5  per  cent,  solution)  with  calcium 
chlorid  (2  per  cent.)  therein.  Dose,  3^  to  i  ounce  (30.0-60.0)  by  mouth, 
repeated  every  four  hours,  is  of  value.  There  are  usually  not  the  indica- 
tions to  relieve  hyperchlorhydria  as  in  ulcer,  so  rectal  feeding  may  be 
instituted  for  twenty-four  hours.  The  ice-bag  should  be  kept  on  for 
several  days.  Gelatin  thereafter  (3  per  cent,  solution)  should  be  used  for 
a  week  in  divided  doses  up  to  12  ounces  (375  c.c.)  in  twenty-four  hours. 
White  of  egg  is  of  value  on  the  following  day,  and  then  fluid  diet,  and  a 
gradual  return  to  the  usual  feeding.  Lactate  calcium,  10  grains  (0.6),  is 
preferable  to  calcium  chlorid.     It  can  be  given  t.i.d. 

Pain. — The  application  of  heat  by  the  hot-water  bag  or  hot  poultices 
is  indicated.  Boas  recommends  3  to  5  drops  of  chloroform  on  ice  to  be 
given  occasionally.  Chloral  hydrate,  3  to  5  grains  (0.2-0.3)  in  water,  has 
been  recommended  by  Ewald,  but  if  the  patient  be  very  weak  it  is  a  danger- 
ous remedy.  Lavage  will  often  relieve  acute  attacks,  especially  if  stenosis 
with  dilatation  are  present. 

Orthoform  or,  preferably,  orthoform  hydrochlorid,  which  is  more 
soluble  in  water,  can  be  given  t.i.d.,  5  to  73^  grains  (0.3-0.5).  The  same 
dose  of  anesthesin  is  at  times  of  service. 

Tincture  belladonna,  10  minims  (0.66)  t.i.d.,  or  extract  belladonna,  H 
^ Trans,  of  New  Hampshire  Med.  Soc,  May  12  and  13,  1910. 


OTHER   TUMORS    OF   THE    STOMACH  363 

grain  (0.022)  t.i.d.,  are  valuable.  Heat,  belladonna,  lavage,  and  ortho- 
form  or  anesthesin  should  first  be  tried.  If  they  fail,  it  may  be  necessary 
to  employ  codein,  preferably,  H  to  M  grain  (0.008-0.032)  by  mouth,  or  }i 
grain  (0.016)  by  hypodermic;  or,  as  a  last  resort,  morphin,  H  to  }i  grain 
(0.008-0.016).     In  terminal  cases  the  opiates  are  indicated. 

Bowels. — For  constipation,  enemata  of  soap  and  water,  with  or  without 
olive  oil,  bowel  irrigation,  injection  of  olive  oil  (8  ounces  to  i  pint  (250- 
500  c.c.)  at  night,  to  be  retained,  rhubarb  pills,  the  cascara  preparations, 
aloin  and  belladonna  compound  pills,  purgen  or  phenolax  tablets,  regulin, 
Russian  or  one  of  the  American  mineral  oils  and  compound  licorice  powder, 
are  all  of  service. 

For  diarrhea,  the  bismuth  preparations,  subnitrate  of  bismuth,  i.o 
to  2.0  (15  grains  to  >2  dram),  several  times  a  day;  or  bismuth  salicylate,  5 
to  10  grains  (0.32-0.64),  three  or  four  times  a  day;  or  subgallate  of  bismuth, 
the  same  dose;  or  subcarbonate  bismuth,  i.o  (15  grains),  three  or  four 
times  a  day,  are  of  value.  Chalk  mixture  or  compound  tincture  catechu 
or  kino,  in  H-dram  (2.0)  doses,  may  be  combined;  or  at  times  tincture 
opii,  10  minims  (0.892),  or  tincture  opii  camphorata,  15  to  30  minims 
(0.888-1.7776  c.c),  may  be  required  in  addition. 

Sten-osis  of  the  Cardia. — This  may  require  cautious  dilatation,  prefer- 
ably with  soft  tubes,  if  possible.  Palliative  gastrostomy  is  preferably 
recommended. 

In  conclusion,  I  desire  to  refer  to  an  interesting  communication  by  the 
late  Carl  Beck.^  In  several  cases  of  intra-abdominal  cancer,  one,  notably 
of  the  pylorus,  incision  was  made  over  the  growth,  and  the  latter  stitched 
to  the  skin,  making  it  practically  cutaneous.  The  .r-rays  were  then  ap- 
plied, with  the  apparent  disappearance  of  the  growth  in  several  cases.  In 
some,  the  wounds  were  allowed  to  granulate,  and  in  others  the  stomach 
was  reduced  after  separation  of  adhesions.  In  some  of  the  cases  the  report 
was  certainly  favorable.  It  would  seem  that  in  cases  of  cancer  of  the 
stomach  in  which  extirpation  is  impossible,  gastro-enterostomy  combined 
with  Beck's  treatment,  just  described,  and  forced  feeding  to  improve  the 
resisting  power  of  the  patient,  might  give  the  best  results. 

OTHER  TUMORS  OF  THE  STOMACH 

Multiple  Polypi  of  the  Stomach  Undergoing  Malignant  Changes. — An 
interesting  case^  of  this  type  has  been  reported  associated  with  multiple 
subcutaneous  telangio-endothelioma,  multiple  lymphangio-endothelioma 
of  the  intestines,  general  vascular  sclerosis,  and  cirrhosis  of  the  liver. 
Vomiting,  dropsy,  and  ascites  were  prominent  symptoms. 

Other  tumors  of  the  stomach  (excepting  carcinoma)  are  comparatively 
rare.  Sarcomata,  Hpomatoma,  fibromata,  and  myomata  have  been  found, 
and  also  polypoid  excrescences  due  to  proliferation  of  the  glands. 

Sarcoma  is  the  most  common  of  these  varieties,  and  may  be  primary  or 
secondary. 

1  On  External  Rontgen  Treatment  of  Internal  Structures  (Eventration  Treatment, 
New  York  Med.  Jour.,  March  27,  1909). 

*  Bull,  of  Johns  Hopkins  Hospital,  July,  1910. 


364  DISEASES  OF  THE   STOMACH  AND  INTESTINES 

Primary  myosarcoma  and  fibrosarcoma  are  generally  in  the  form  of 
circumscribed  nodules  in  the  stomach-wall,  while  lymphosarcoma  is  flatter 
and  infiltrates. 

The  tumors  vary  in  size  and  form,  and  are  situated  generally  on  the 
greater  curvature.     Metastases  are  frequent. 

Harlow  Brooks  believes  the  growth  usually  appears  at  the  lesser  curva- 
ture of  the  stomach,  though  it  may  occur  in  other  regions.  It  may  be 
multiple. 

Primary  lymphosarcoma  appears  most  frequently  between  twenty 
and  thirty-five  years  of  age,  while  the  other  types  occur  more  frequently 
in  older  subjects.  It  has  occurred  at  the  age  of  three  and  a  half  years. 
The  cases  are  about  equally  divided  as  to  sex.  Corner^  and  Fairbank 
report  58  cases. 

Symptoms  of  Sarcoma  of  the  Stomach. — These  appear  somewhat 
insidiously,  in  some  cases  gradual  emaciation  being  first  noted;  the  stomach 
symptoms  are  practically  the  same  as  in  carcinoma:  loss  of  appetite,  sour 
belching,  a  feeling  of  pressure  and  fulness,  disagreeable  taste,  pain,  vomit- 
ing, and,  finally,  coffee-grounds  in  the  vomitus.  Dilatation  of  the 
stomach,  if  pyloric  involvement,  and  tetany  have  been  observed  in  this 
type  of  case.  Some  of  the  cases  run  a  rapid  course,  with  marked  anemia, 
with  an  absence  of  hematemesis  and  no  gastric  dilatation,  though  the 
tumor  grows  rapidly  in  size. 

Gastric  Analysis. — Absence  of  free  hydrochloric  acid;  presence  of  lactic 
acid;  Boas-Oppler  bacilli  are  frequently  present. 

In  effect,  we  may  say  the  gastric  findings  and  symptoms  are  similar  to 
carcinoma. 

The  methods  of  physical  examination  are  the  same  as  in  carcinoma  of 
the  stomach. 

Average  duration  is  from  one  to  one  and  a  half  years.  Schlesinger 
and  Kundrat  have  shown  that  certain  factors  may  be  utilized  for  the 
purpose  of  differential  diagnosis. 

Metastases  of  the  skin  are  more  frequent  with  sarcoma,  and  excision, 
with  examination  of  a  cutaneous  nodule,  when  such  is  present,  will  afford 
positive  information.  Metastases  in  the  intestines  occur  more  frequently 
with  lymphosarcoma,  and  these  do  not  produce  stricture,  but  dilatation; 
while  carcinoma  causes  stenosis  of  the  gut. 

The  lymph-glands  are  more  swollen  in  sarcoma. 

The  spleen  is  also  swollen  in  sarcoma,  not  so  in  carcinoma. 

The  tongue  follicles  are  at  times  swollen  and  tumefied  and  infiltration 
of  the  tongue  may  occur;  there  is  a  symmetric  arrangement  of  the  ridges, 
nodules,  and  papillae. 

Treatment. — Early  surgical  operation,  if  possible,  the  indication  being 
the  same  as  in  carcinoma. 

Lavage  is  indicated  if  dilatation  be  present.  Coley's  fluid  (erysipelas 
toxin  and  bacillus  prodigiosus)  has  proved  of  value,  especially  in  some  cases 
of  sarcoma,  and  should  be  tried  in  inoperable  cases.  Severe  reaction  and 
renal  disturbance  may  follow  its  use,  so  it  should  be  employed  with  caution. 

'  Practitioner,  1904,  Ixxii,  810. 


OTHER   TUMORS   OF   THE    STOMACH  365 

Hematemesis  should  be  treated  as  when  it  occurs  in  carcinoma  as  should 
other  complications. 

The  diet  should  be  the  same  as  in  carcinoma,  and  the  use  of  stomachics 
oxyntin  with  nux  vomica,  etc. 

Arsenic  (Fowler's  solution),  beginning  at  5  minims  (0.296)  and  gradu- 
ally increasing  to  15  minims  (0.888),  t.i.d.,  can  be  tried  in  lymphosarcoma. 

Benign  Tumors. — Benign  tumors  of  the  stomach  are  a  rarity  and  prac- 
tically impossible  to  differentiate  in  many  cases.  Polypi  are  the  most 
common,  though  fibroma,  lipoma,  myoma  and  rarely  chondroma  or 
osteoma  have  occurred.  Angiomas  and  cysts  are  occasionally  found,  but 
the  latter  occur  most  frequently  as  result  of  degenerative  changes  in  a 
myoma.  Lymphomas  occur  with  leukemia.  About  84  cases  of  myoma 
were  collected  up  to  igi2  and  Farr^  reports  an  interesting  case  charac- 
terized by  tarry  stools  and  hematemesis.  No  tumor  could  be  palpated  and 
the  clinical  diagnosis  of  gastric  ulcer  was  made.  Myomas  furthermore 
tend  to  undergo  sarcomatous  degeneration.  Myomas  may  be  internal 
when  they  are  usually  of  small  size  and  may  produce  no  marked  symptoms 
unless  involving  the  pylorus,  when  stenotic  symptoms  would  ensue. 
There  may  be  some  epigastric  pain  when  involving  the  body  of  the  stom- 
ach and  disturbance  of  appetite.  If  ulcerative  then  hematemesis  and 
melena  occur  suggestive  of  ulcer.  Sometimes  emesis  without  blood  soon 
after  eating  occurs.  With  external  myoma  (i.e.,  of  the  body-wall)  the 
mass  sometimes  grows  to  considerable  size.  The  cachexia  and  gastric 
findings  of  malignancy  would  be  absent  in  benign  tumors. 

When  producing  benign  pyloric  stenosis,  a  tumor  (thickening)  is  pal- 
pable in  some  cases,  but  the  symptoms  would  be  of  benign  stenosis,  with 
dilatation  of  the  stomach,  cachexia  absent,  and  usually  hyperacid  gastric 
contents. 

Occasionally  a  small  tumor  has  been  noted  lying  on  the  greater  curva- 
ture, due  to  enlargement  of  a  lymph-gland  secondary  to  an  inflamed  ulcer. 

Polyposis  Gastrica  (Polyadenoma). — This  condition  is  quite  rare. 
Ebstein  reported  22  cases  of  gastric  poljqis  and  Menetrier  made  a  thorough 
study  of  the  subject.  A  number  have  reported  single  polyps  of  the  stom- 
ach, but  multiple  polyps  are  quite  rare. 

Etiology. — Chronic  gastritis  is  an  important  factor  (the  hypertrophic 
type)  though  they  may  develop  independently.  The  condition  occurs 
with  advancing  years  and  atheroma  of  the  vessels  is  always  present 
and  hence  changes  occur  in  the  mucosa  resulting  from  disturbance  of  the 
nutrition. 

Age. — Two  cases  are  reported  respectively  thirty-four  and  thirty-six 
years,  while  most  of  them  are  older — over  fifty  years.  It  seems  more 
frequent  in  males. 

Pathology.— MsLCToscopicaWy  the  polyps  are  small  pediculated,  in  size 
from  a  lentil  to  a  pea,  gray  or  reddish  in  color,  and  soft  in  consistency. 
They  are  generally  covered  with  mucus  and  are  pigmented.  Menetrier 
describes  a  type  in  which  hypertrophy  and  hyperplasia  involve  chiefly  the 
excretory  part  of  the  tubular  glands — in  which  lobulation  is  more  apparent 
and  cysts  are  more  common.  When  the  deeper  portion  is  involved  the 
^  N.  Y.  Med.  Jour.,  June  28,  1913. 


366  DISEASES   OF   THE    STOMACH    AND   INTESTINES 

polyps  are  more  uniform  in  appearance  and  the  tubulation  is  less  pro- 
nounced. The  mucosa  between  the  polyps  usually  shows  the  character- 
istics of  a  chronic  gastritis. 

Microscopically  there  is  a  central  stalk  of  connective  tissue  which 
contains  the  blood-vessels  and  lymphatics.  Next  comes  the  muscularis 
mucosae  and  over  this  excessive  growth  of  mucosa  with  elongated,  dilated 
and  tortuous  glands — some  of  which  form  cysts  filled  with  mucus. 

Menetrier  describes  a  more  rare  condition  which  occasionally  occurs, 
known  as  polyadenome  en  Nappe,  in  which  the  hypertrophic  mucosa 
develops  in  large  plagues  over  the  stomach  and  not  as  polyps. 

Location. — The  single  polyps  generally  occur  near  the  pylorus,  while 
the  multiple  ones  are  widely  distributed,  but  chiefly  at  the  pyloric  end. 

Symptoms. — Sometimes  there  may  be  none  especially  if  the  fundus 
alone  is  afifected.  If  there  is  a  polypi  near  the  pylorus  causing  obstruction, 
we  may  have  nausea,  vomiting,  gastric  dilatation  and  other  symptoms  of 
pyloric  stenosis.  In  other  situations  there  may  be  belching,  discomfort, 
nausea,  and  at  times  vomiting. 

The  gastric  analysis  may  show  marked  hypochlorhydria  with  some 
mucus,  there  may  be  achylia.  Red  cells  (microscopic)  may  be  present  in 
marked  cases  with  leukocytes  or  occult  blood  or  even  visible  blood. 
Hematemesis  and  melena  may  occur.  In  several  cases  a  small  polyp  has 
been  found  in  the  wash  water  or  partly  digested  in  the  stool. 

Diagnosis. — This  is  difficult  except  in  cases  with  hypochlorhydria  with 
excessive  mucus — suggestive  of  progressive  chronic  gastritis  or  achylia 
which  in  connection  with  gastric  hemorrhage  would  be  indicative  of  the 
probability  of  a  polypoid  condition.  The  Radiograph  shows  irregularity 
in  the  contour  of  the  stomach. 

Treatment. — Operation  with  enucleation  of  the  growth  or  partial  resec- 
tion would  be  successful  in  case  of  a  single  or  a  few  polypi.  Exploration 
would  be  indicated  in  any  event. 

APPARENT  TUMORS  OF  THE  STOMACH 

Einhorn*  has  described  cases  of  apparent  tumors  erf  the  abdomen  which 
have  been  mistaken  for  tumors  of  the  stomach,  notably,  prolapse  of  the 
left  lobe  of  the  liver,  exposure  of  the  aorta  (abdominal)  from  gastroptosis, 
thickening  of  the  abdominal  muscles  (recti),  and  adhesions  of  the  lesser 
curvature,  Enteroptosis  of  a  considerable  degree  is  usually  associated 
with  the  first  two  conditions  and  the  history  is  a  long  one.  Pulsation  of 
the  aorta  may  be  mistaken  for  aneurysm.  Cirrhosis  of  left  lobe  of  liver 
may  simulate  cancer  of  the  stomach  on  palpation.  The  gastric  analysis 
and  other  symptoms  will  differentiate  these  conditions.  With  gastropto- 
sis the  pancreas  has  been  palpated  and  mistaken  for  gastric  tumors.  In 
some  cases  a  transient  tumor  in  the  region  of  the  stomach,  dependent 
evidently  on  spasm,  as  from  ulcer,  has  been  noted.  Schnitzler^  observed 
such  a  case. 

Thickening  of  the  recti  is  diagnosed  as  follows:  The  thighs  and  knees 

^  Med.  Rec,  Nov.  24,  1900. 

*  Centralb.  f.  Chir.,  Sept.  3,  1898. 


FOREIGN  BODIES   IN   THE   STOMACH 


367 


are  well  flexed,  and  the  head  and  shoulders  elevated,  so  as  to  produce 
marked  relaxation  of  the  abdominal  muscles.  It  will  then  be  possible  to 
slip  the  finger-tips  beneath  the  edges  of  the  relaxed  and  thickened  rectus 
muscle.  With  adhesions,  pain  on  distention  of  the  stomach,  motor  dis- 
turbances, etc.,  are  present.     (See  Perigastritis.) 

FOREIGN  BODIES  IN  THE  STOMACH 

These  may  be  swallowed  accidentally  or  purposely,  or  may  be  gradu- 
ally deposited  in  the  stomach. 


Fig. 


201. — A  human  hardware  store.     A  collection  of  foreign  bodies  found  at  necropsy 
in  the  stomach  of  an  insane  patient  (Vandivert  and  Mills). 


Among  such  articles  are  pins,  needles,  scarf-pins,  knives,  spoons,  forks, 
artificial  teeth,  glass,  hooks,  pens,  buttons,  balls  of  hair,  bits  of  iron,  nails, 
lead,  wood,  and  even  the  stomach-tube.  Lunatics,  idiots,  and  young  chil- 
dren frequently  swallow  foreign  bodies,  as  do  trick  knife-swallowers. 
Cases  have  been  reported  of  patients  who  have  worked  with  an  alcoholic 
solution  of  shellac,  and  who  had  swallowed  small  quantities  daily,  with 


368  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

the  ultimate  formation  of  stones  in  the  stomach.     Sarcinae  ventriculi  have 
also  accumulated  in  large  numbers  and  formed  a  tumor. 

An  interesting  case  of  the  ingestion  of  foreign  bodies  by  a  lunatic 
is  reported  by  Vandivert  and  Mills^  from  State  Hospital  No.  2,  St.  Joseph, 
Missouri.  This  patient  died  apparently  of  nephritis  and  there  was  no 
suspicion  of  gastric  trouble  until  autopsy.  The  mass  of  foreign  material 
lay  on  the  sacculated  portion,  leaving  a  narrow  channel  along  the  lesser 
curvature  for  the  passage  of  food.  There  was  an  atrophy  of  the  mucous 
membrane,  much  formation  of  connective  tissue,  erosions,  and  the  points 
of  some  of  the  foreign  bodies  had  penetrated  the  stomach- walls,  but  adher- 
ing omentum  prevented  leakage.  There  were  some  small  walled-in 
abscesses.  The  appetite  remained  good  until  two  weeks  before  death,  and 
no  symptoms  pointed  to  the  stomach.  In  all,  1446  objects  were  found  in 
the  stomach.  As  a  matter  of  interest  the  list  is  given,  also  a  photograph 
(Fig.  201)  of  the  material  found  in  the  organ. 


List 

Nails 

20-penny 5 

i6-penny 21 

lo-penny , 24 

8-p>enny 80' 

S-penny 113 

3-penny 210 

Total 453       453 

Screws 

2yi  inches 4 

i)^  inches 11 

i34  inches ■. 5 

I      inch 9 

^  inch 6 

yi  inch 7 

Total 42        42 

Bolts 

%    X  I      inch 3 

%    Xi%  inches i 

He  X  2}4  inches i 

^    X  2      inches i 

^6  X  I      inch 3 

Total 9          9 

Miscellaneous 

Teaspoon  handles 5 

Nail-file,  3}^  inches i 

Pieces  of  steel,  2^^  inches 3 

Thimbles 5 

Salt-shaker  tops 3 

Taps  for  %-inch  bolts 10 

Buttons 63 

^  Jour.  Amer.  Med.  Assoc.,  Jan.  21,  191 1. 


FOREIGN  BODIES  IN  THE  STOMACH  369 

Safety-pins 105 

Hairpins 115 

Carpet-tacks ". 52 

Common  pins 136 

Large  white-headed  pins,  2^  X  ^  inches 16 

Needles 37 

Broken  coat-rack  hooks,  2  X  ^  inches 7 

String  beads,  small,  4  feet  long i 

Larger  beads,  loose 70 

Small  stones  and  pieces  of  glass 85 

Prune  seeds 7 

Pieces  of  metal,  combined  weight  3  ounces 54 

Hooks  and  eyes 19 

Grape,  and  other  small  seeds 148 

Total 942       942 

Making  a  combined  total  of 1446 

Weight 21,268  gm. 

There  may  be  local  disturbances  of  severe  type  and  vomiting,  or  if 
damage  be  done  to  the  mucous  membrane,  then  hemorrhage.  On  the 
other  hand,  there  may  be  no  disturbances  at  all,  and  the  foreign  body, 
especially  if  of  small  size  and  smooth,  may  be  evacuated  from  the  bowels. 
The  history  of  the  case  will  generally  give  us  information.  If  the  tumor 
be  of  sufficient  size  and  very  movable,  it  can  be  at  times  appreciated  by 
palpation. 

The  a:-rays  will  give  information  as  to  its  presence  and  location. 

Treatment. — The  use  of  an  emetic  is  objectionable,  as  a  rule,  unless 
the  foreign  body  is  extremely  small  and  smooth.  Personally,  I  never 
employ  it.  Mayou  has  recommended  the  use  of  an  electromagnet  in- 
serted in  a  stomach-tube,  there  being  sufficient  space  at  the  end  of  the 
tube  to  draw  in  a  small  metallic  object  which  can  be  located  by  the  a;-rays. 

Under  usual  conditions,  the  administration  of  constipating  food,  pota- 
toes, rice,  and  the  soft  part  of  bread,  and  keeping  the  bowels  costive  for 
several  days,  so  as  to  form  a  protective  mass  about  the  foreign  body,  is 
the  best  method  of  treatment.  It  is  an  error  to  immediately  administer 
a  cathartic,  as  damage  is  done  to  the  intestinal  canal  if  there  be  any  sharp 
edges  to  the  object.  Complications,  such  as  perforation  or  inflammatory 
adhesions,  are  liable  to  occur  if  it  be  of  any  size.  Intestinal  obstruction 
may  even  result.  If  the  body  is  of  large  size  or  serious  symptoms  ensue, 
early  gastrotomy  is  indicated.  The  author's  inflating  gastroscope  inserted 
through  the  gastric  incision  is  a  valuable  aid  through  which  to  remove 
the  foreign  body.  Occasionally  a  small  foreign  body  may  be  located  by 
the  gastroscope  and  removed  through  it  by  long  forceps, 
24 


CHAPTER  XIV 
FUNCTIONAL  DISEASES  OF  THE  STOMACH 

Under  functional  diseases  of  the  stomach  we  may  classify  those  affec- 
tions in  which  either  the  secretory  or  motor  functions  of  the  stomach  are 
at  fault.  Anatomic  lesions  are  present  in  some  cases  and  are  absent  in 
others. 

The  principal  symptoms  are  due  to  the  disorders  of  secretion  or  mo- 
tility. Among  these  we  classify  hyperacidity  (hyperchlorhydria),  hyper- 
secretion (gastrosuccorrhea),  atony  of  the  stomach,  dilatation  of  the 
stomach,  and  achylia  gastrica. 

Many  cases  of  hyperacidity  and  of  hypersecretion  are  pure  secretory 
neuroses,  or  they  may  be  reflex  or  due  to  vagotonia;  atony  may  also  result 
from  nervous  disorders,  but  there  are  other  causes  for  these  conditions. 

When  there  is  dilatation  due  to  stenosis  of  the  pylorus,  as  from  malig- 
nant tumor,  the  symptoms  are  due  to  the  cancer  and  also  to  the  relative 
motor  insufficiency.  It  is  difficult,  therefore,  to  place  any  special  disease 
of  the  stomach  under  a  pure  classification,  owing  to  the  diverse  etiology. 
With  achylia  gastrica  we  have  the  loss  of  secretory  functions  of  the  stom- 
ach, and  it  may  be  classified  under  functional  diseases.  It  is  produced 
either  by  nervous  influences  or  by  anatomic  changes  in  the  gastric  mucous 
membrane.  As  in  many  cases  organic  changes  are  present,  I  judged  it 
advisable  to  devote  to  it  a  separate  chapter. 

HYPERACIDITY  (HYPERCHLORHYDRIA) 

{Synonyms. — Hyperaciditas  Hydrochlorica;  Superacidity) 

The  term  "hyperchlorhydria"  should  be  used  to  designate  an  increased 
secretion  of  gastric  juice  or,  more  correctly,  of  hydrochloric  acid,  during 
the  period  of  digestion;  that  is,  an  overproduction  of  this  acid.  Under 
normal  conditions  the  free  hydrochloric  acid  fluctuates  in  the  stomach 
within  certain  limits,  thus: 

Free  HCl  averages  between  25+  and  50-I-,  or  about  o.i  to  0.2  per 
cent.,  and  the  total  acidity  is  from  40-I-  to  65-I-,  or  0.146  to  0.237  per 
cent. 

We  speak  of  hyperchlorhydria  when  not  only  the  total  acidity  is  higher 
than  normal,  but  when  the  excess  of  free  HCl  is  above  normal.  It  is  not 
sufficient  to  merely  test  for  the  total  acidity,  as  it  may  be^  increased  by 
organic  acids.     The  free  HCl  should  be  determined  quantitatively. 

We  might  place  a  total  acidity  of  70+,  of  which  the  greater  part  con- 
sists of  free  hydrochloric  acid,  on  the  dividing  line.  A  patient  with  such 
a  degree  of  acidity  and  complaining  of  clinical  symptoms  may  be  consid- 
ered a  case  of  hyperchlorhydria. 

A  total  acidity  of  100  to  120,  with  free  HCl,  80+  to  90-f ,  is  quite 

^  In  the  mild  types  of  hyperchlorhydria,  however,  the  free  HCl  may  be  within 
normal  limits,  but  the  addition  of  the  combined  HCl  brings  the  total  HCl  above 
normal  limits  for  such  and  the  patients  have  symptoms. 

370 


FUNCTIONAL  DISEASES   OF  THE   STOMACH  37I 

common,  and  much  greater  degrees  of  hyperchlorhydria  have  been 
observed. 

We  must  remember  that  individual  idiosyncrasies  exist  as  to  the  sus- 
ceptibility to  free  HCl.  We  occasionally  find  patients  with  a  total  acidity 
of  100+,  the  greater  part  of  which  is  free  HCl,  who  have  no  subjective 
disturbances  whatever  and  never  suffer  any  discomfort.  In  this  regard 
an  unusual  case  is  reported  by  Verbrycke,^  a  patient  of  Morgan,  with  free 
hydrochloric  acid  154+,  or  0.56  per  cent.,  and  a  total  acidity  of  204+, 
or  0.74  per  cent.,  with  only  slight  pains  after  meals.  One  must  also  re- 
member that  there  may  be  a  small  amount  of  gastric  juice  with  high 
acidity,  or  a  larger  amount  with  lower  percentage,  but  high  total  content 
of  hydrochloric  acid.  Moreover,  bacteria  may  be  present  when  there  is 
considerable  hydrochloric  acid,  their  presence  then  indicating  diminished 
motility. 

On  the  other  hand,  I  have  at  present  a  patient  under  treatment  with 
a  total  acidity  of  60+  and  free  HCl  40-I-,  who  has  all  the  symptoms  of 
hyperchlorhydria. 

Frequency. — It  was  formerly  thought  that  in  most  diseases  of  the 
stomach  the  gastric  secretion  was  deficient,  but  it  has  been  demonstrated 
that  the  gastric  juice  is  increased  in  about  one-half  the  cases. 

One  does  not  see  so  many  cases  of  hyperchlorhydria  in  hospital  prac- 
tice, except  in  connection  with  gastric  ulcer,  since  the  symptoms  rarely 
become  so  severe  as  to  require  hospital  treatment.  As  a  concomitant  of 
chlorosis  it  is  frequently  found.  The  gastric  analysis  in  these  cases  is 
often  neglected.  Moreover,  the  general  practitioner  rarely  examines  the 
gastric  contents  in  cases  which  present  the  symptoms  of  hyperacidity. 
It  is,  therefore,  difficult  to  secure  statistics  as  to  its  frequency. 

Einhorn  reports  a  trifle  more  than  one-half  his  patients,  to  be  sufferers 
from  hyperchlorhydria.  Records  of  my  private  patients  show  that  about 
50  per  cent,  come  to  me  for  treatment  for  this  condition. 

Etiology. — No  age  is  exempt.  It  is  met  with  in  adults  and  quite  fre- 
quently in  young  people.  In  some  cases  it  is  a  neurosis.  Nervous  excite- 
ment, violent  emotions,  sorrow,  worry,  and  severe  mental  labor  may  be 
direct  causes. 

Neurasthenics  and  melancholies  often  suffer  from  it.  Vagotonia  is 
a  cause  in  some  cases.  It  is  a  frequent  concomitant  of  gastroptosis.  In 
this  condition  the  hyperchlorhydria  is  not  the  result  of  the  nervous  condi- 
tion alone,  but  in  part  due  to  the  ptosis,  with  resulting  circulatory  changes. 
Its  relief  by  Rose's  belt  is  the  proof,  as  reported  in  a  series  of  cases  at  the 
Manhattan  State  Hospital.^  It  occurs  with  mucous  colic,  in  which  case 
I  believe  gastroptosis  is  a  factor. 

Chlorosis  is  a  frequent  cause.  Irritation  of  the  mucous  membrane 
of  the  stomach  may  be  a  direct  factor,  as  from  bolting  the  food,  large 
quantities  of  cold  or  hot  drinks,  alcohoUc  excess,  pickles,  rich  condiments, 
and  insufficient  mastication. 

Special  articles  of  food  or  drink  are  often  productive  of  it,  such  as  very 

1  N.  Y.  Med.  Jour.,  July  16,  1910. 
*  Rose  and  Kemp,  Atonia  Gastrica. 


372  DISEASES  OF  THE   STOMACH  AND  INTESTINES 

Strong  coffee.  Deeks^  and  Stone^  hold  that  excessive  sugar  and  starch 
diet  producing  butyric  acid  fermentation  are  factors  in  causing  hyper- 
acidity, hypersecretion,  and  ulcer.  Excessive  smoking  and  chewing  of 
tobacco  are  also  factors. 

Chronic  appendicitis,  cholelithiasis,  cholecystitis  and  nephrolithiasis 
are  causes.     Spasm  of  the  pylorus  may  accompany  these  conditions. 

Hyperchlorhydria  is  a  frequent  accompaniment  of  gastric  ulcer.  This 
is  particularly  true  of  the  acute  ulcer.  It  may  accompany  duodenal  ulcer, 
and  is  found  with  benign  stenosis  and  dilatation  of  the  stomach,  and  with 
gastrosuccorrhea.  It  is  more  frequent  among  the  wealthy  class,  such  as 
bankers,  brokers,  and  professional  men,  though  it  occurs  among  the  poor. 
There  seems  to  be  no  special  predilection  for  either  sex. 

Kaufmann^  calls  to  our  attention  that  hyperacidity  may  in  some  in- 
stances precede  the  gall-bladder  trouble  and  holds  that  the  constant  irrita- 
tion of  the  duodenum  by  the  very  acid  stomach  contents  may  cause  a 
spasm  of  the  opening  of  the  common  duct  with  resulting  retention  and 
inflammation  thus  causing  infectious  cholangitis  or  gall-stones.  Arpad 
Gerster"*  refers  to  this  probability. 

Sjnnptoms. — They  rarely  appear  suddenly,  but  usually  develop  gradu- 
ally. They  always  come  on  after  eating  and  never  on  an  empty  stomach, 
after  the  time  for  digestion  has  elapsed.  At  first  the  patient  complains 
of  a  disagreeable  sensation  or  any  uneasy  feeling,  about  one  to  three  hours 
after  a  meal.  It  may  be  a  feeling  of  pressure  or  fulness,  or  of  heat,  or  of 
tingling.  This  increases  into  a  feeling  of  distress  in  the  epigastric  region, 
or  a  burning  sensation  after  each  meal.  In  the  mild  cases  there  is  no 
actual  pain. 

In  severe  cases  pain  may  be  marked,  with  acid  belching  and  heart- 
burn, and  the  patients  suffer  severely  and  in  some  cases  appear  almost  in 
a  state  of  collapse.  The  burning  may  be  felt  in  the  esophagus  or  along 
the  back,  and  is  due  to  the  eructation  of  the  acid  contents.  Violent  head- 
ache often  accompanies  it.  Some  claim  they  can  feel  spasmodic  move- 
ments in  the  stomach.  This  is  due  to  contraction  (spasm),  of  the  pylorus 
and  an  increased  peristaltic  action  of  the  organ  endeavoring  to  overcome 
the  obstacle.  Mild  attacks  of  pain  last  for  a  brief  period  of  time,  while 
the  more  severe  attacks  persist  for  several  hours. 

Vomiting  occurs  occasionally  during  the  height  of  the  cardialgic  at- 
tacks. The  vomitus  is  very  acid  and  burning,  and  after  its  occurrence 
relief,  as  a  rule,  results. 

In  some  cases  the  pain  appears  after  eating  certain  articles  of  food,  and 
patients  seem  to  have  idiosyncrasies,  such  as  to  coffee,  etc.  The  attacks 
are  not  always  directly  dependent  on  the  degree  of  the  digestibility  of  the 
food,  and  at  times  they  can  eat  indigestible  material  without  discomfort; 
whereas  at  other  times  digestible  articles  of  diet  will  cause  pain.  Prob- 
ably the  nervous  element  plays  a  part  in  these  cases,  causing  undue  irrita- 
tion of  the  nerves  of  secretion. 

^N.  Y.  Med.  Jour.,  Nov.  30,  1912. 

^Journal  A.  M.  A.,  (Stone),  Jan.  29,  1916. 

'  Amer.  Med.,  Nov.,  1903,  vi;  also  Journal  A.  M.  A.,  July  26,  1913. 

*  Surgery,  Gyn.  and  Obstet.,  Nov.,  191 2. 


FUNCTIONAL  DISEASES   OF  THE   STOMACH  373 

Some  suffer  more  disturbance  after  a  small  meal,  while  after  a  large 
meal  they  have  no  distress.  This  is  readily  explained  by  the  fact  that  the 
larger  amount  of  food  combines  with  a  greater  portion  of  the  free  HCl 
secreted. 

Patients  when  the  symptoms  first  appear  can  ease  their  pain  by  taking 
nourishment,  especially  if  rich  in  albumin,  as  the  whites  of  eggs  and  milk 
or  meat.  It  also  disappears  after  the  administration  of  an  alkali,  such  as 
milk  of  magnesia  (Phillips),  Vichy,  or  soda  bicarbonate.  Persons  living 
chiefly  on  a  starch  diet  suffer  more  intense  pain  than  those  who  live  largely 
on  meat  and  eggs;  hence,  the  character  of  the  food  has  frequently  a  relation 
to  the  pain. 

Appetite. — In  most  cases  the  appetite  is  very  good,  and  in  some  is 
greatly  increased.  Others  are  readily  satiated,  but  the  desire  for  food  soon 
comes  on  again. 

Thirst  is  at  times  increased  during  the  active  attack,  but  in  many  cases 
is  normal.  If  hyperchlorhydria  is  complicated  by  dilatation  of  the  stom- 
ach, thirst  is  present. 

Bowels. — Constipation  is,  as  a  rule,  present,  though  constipation  and 
diarrhea  may  alternate. 

Headache. — Severe  headache  often  occurs,  or  even  attacks  of  dizziness, 
generally  during  the  occurrence  of  gastric  pain. 

NtUrition. — These  patients  generally  do  not  lose  in  weight  nor  present 
the  aspect  of  being  very  sick.  They  are  rarely  particularly  well  nourished 
and  are  often  of  nervous  temperament  or  anemic.  This  is  not  invariable, 
as  one  has  at  times  to  treat  stout,  well-nourished  men,  high  livers,  and 
inveterate  smokers  and  drinkers,  who  suffer  from  this  complaint.  Rarely, 
under  improper  diet,  loss  of  weight  may  occur. 

Nervous  Symptoms. — Some  patients  are  depressed,  nervous,  suffer  from 
insomnia,  and  are  neurasthenic.     Migraine  occurs  in  others. 

Urine. — Acidity  of  the  urine  may  be  reduced  during  the  course  of 
digestion.     There  are  no  characteristic  features. 

Physical  Exatnination  of  the  Stomach. — During  intervals  between  at- 
tacks there  may  be  nothing  in  evidence. 

Percussion. — At  the  time  of  the  attack  the  stomach  may  be  distended. 
Palpation. — In  mild  cases  there  will  be  no  tenderness.  The  greater 
part  of  the  gastric  region  will  be  found  to  be  tender  on  pressure  or  even 
painful  in  severer  cases.  The  tenderness  covers  a  large  area,  generally 
over  the  greater  part  of  the  stomach ;  often  in  the  region  of  the  pylorus  this 
tenderness  is  accentuated. 

Splashing  Sound. — This  can  be  produced  after  meals  or  after  the  inges- 
tion of  water,  but  is  not  present  in  the  fasting  condition. 

Examination  of  the  Stomach  Contents. — This  is  the  decisive  test.  If  the 
stomach  is  aspirated  in  the  fasting  condition,  it  is  found  to  be  empty,  or 
only  a  few  cubic  centimeters  of  juice  can  jpe  secured. 

One  hour  after  Ewald's  test-breakfast  or  three  to  four  hours  after  the 
Leube-Riegel  test-dinner  the  stomach  contents  show  an  extremely  acid 
reaction,  often  two  to  three  times  higher  than  normal  (from  loo-l-  to 
150+). 

It  is  not  sufficient  to  determine  the  total  acidity,  but  the  value  of  the 


374  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

free  hydrochloric  acid  is  the  important  feature.  Only  in  hyperchlorhydria 
is  it  increased,  and  in  this  condition  the  free  HCl  causes  the  high  degree 
of  acidity;  and  Topfer's  test  (dimethyl-amido-azobenzol)  shows  that  the 
free  hydrochloric  acid  constitutes  the  chief  content,  and  is  often  within 
IO+  to  15+  of  the  total  acidity.     Mintz's  method  is  also  excellent. 

The  digestive  power  is  very  good;  a  small  disk  of  egg-albumen  will  be 
digested  in  a  short  time,  sometimes  within  one-half  to  one  hour.  Three 
to  four  hours  after  the  test-dinner  meat  will  be  found  to  be  perfectly 
digested,  while  starchy  substances  will  be  at  times  unchanged  or  little 
altered. 

Starch  or  erythrodextrin  will  be  found,  Lugol's  solution  giving  a  blue 
or  dark  red  reaction.  If,  however,  a  small  amount  of  starchy  food  be 
given  with  a  large  amount  of  albuminous  material,  while  the  HCl  is  enter- 
ing into  combination  and  before  free  hydrochloric  acid  appears,  the  normal 
reduction  changes  in  the  starch  may  occur.  With  large  quantities  of 
amylaceous  material  the  brief  period  before  the  appearance  of  hyperchlor- 
hydria will  not  allow  a  complete  conversion  of  all  the  starch,  and  this 
tends  to  remain  in  the  stomach  an  abnormally  long  time  and  to  produce 
fermentation. 

A.  L.  Benedict^  describes  an  effervescent  test  for  gastric  acidity.  He 
administers  30  to  50  c.c.  of  a  strongly  saturated  solution  of  sodium  bi- 
carbonate, to  be  taken  at  a  single  gulp,  and,  preferably,  by  means  of  a 
stethoscope,  determines,  by  the  degree  of  effervescence,  the  degree  of 
acidity.  This  method  is  only  relative.  Boardman  Reed  has  experi- 
mented with  the  method.     The  writer  does  not,  however,  recommend  it. 

Absorption  from  the  stomach  is  not  disturbed;  potassium  iodid  appears, 
if  anything,  more  rapidly  in  the  saliva. 

Motor  Function. — This  is  not  impaired,  but  is  often  rather  increased. 
Two  hours  after  the  test-breakfast  or  six  to  seven  hours  after  the  test- 
dinner  the  organ  is  found  to  be  empty  or  nearly  so.  Salol  appears  as 
salicyluric  acid  in  the  urine  an  hour  after  its  ingestion  when  tested  for 
with  ferric  chlorid  solution.  We  must-  remember  that  hyperchlorhydria 
untreated,  with  fermentation  resulting  from  improper  diet  (excessive 
starch),  may  in  some  cases  produce  atony  and  resulting  insufficiency. 
Hypersecretion,  which  may  accompany  hyperchlorhydria,  is  another 
factor. 

Course. — It  may  be  rapid,  coming  on  suddenly  and  lasting  a  short 
time,  or  chronic,  for  months  to  years.  It  often  varies  in  the  early  stages 
and  may  be  intermittent  in  its  character.  The  attack  may  last  for  days, 
weeks,  or  even  months,  and  then  there  be  a  free  interval  for  a  considerable 
period  of  time.  It  can  recur  without  any  apparent  cause,  or  result  from 
some  mental  shock  or  worry,  or  from  some  dietary  indiscretion.  Gradu- 
ally the  hyperchlorhydria  becomes  more  frequent  and  at  last  the  condition 
becomes  permanent.  , 

In  rare  cases  the  attacks  appear  to  come  on  later  than  usual,  and 
vomiting  of  an  acid  mass  of  undigested  food  may  occur,  showing  the  con- 
tents were  retained  an  abnormally  long  time.  This  is  undoubtedly  due 
to  spasmodic  closure  of  the  pylorus  from  irritation  by  the  acid  contents. 
^  N.  Y.  Med.  Jour.,  May  ii,  191 1. 


FUNCTIONAL  DISEASES   OF  THE   STOMACH  375 

Atony  and  even  atonic  dilatation  may  develop  from  this  type,  and 
hypersecretion  (gastrosuccorrhea)  may  result  in  some  cases. 

Prognosis. — The  prognosis  is,  as  a  rule,  good.  Many  patients  can  be 
completely  cured.  In  some  very  old  or  severe  cases  there  is  a  tendency  to 
relapses.     The  disease  is  not  dangerous  to  life. 

Those  in  whom  the  nervous  element  plays  a  part  often  do  not  readily 
respond  to  treatment  and  are  a  source  of  discouragement  to  the  physician. 
Relapses,  in  spite  of  the  greatest  care  and  for  no  apparent  reason,  are  not 
infrequent. 

If  atony,  dilatation  of  the  stomach  or  hypersecretion  complicate  the 
hyperchlorhydria,  the  prognosis  as  to  cure  is  not  as  favorable. 

Pathology. — As  the  cases  are  not  fatal,  it  is  hence  unknown.  In  one 
case,  dying  of  intercurrent  disease,  a  few  erosions  were  found.  It  is  evi- 
dently a  disorder  of  the  secretory  function. 

Diagnosis. — The  diagnosis  of  hyperchlorhydria  can  be  made  from  the 
examination  of  the  gastric  contents: 

1.  An  hour  after  Ewald's  test-breakfast  the  acidity  is  found  increased, 
due  to  the  increased  quantity  of  free  hydrochloric  acid. 

2.  In  the  fasting  condition  the  stomach  is  found  empty  or  nearly  so. 
(This  excludes  gastrosuccorrhea.) 

Furthermore,  the  patient  suffers  from  certain  subjective  symptoms: 

1.  Discomfort  or,  more  generally,  a  pain  which  comes  on  from  one  to 
three  hours  after  a  meal.  This  is  directly  dependent  upon  the  ingestion 
of  food.  It  is  not  a  continuous  pain  and  there  are  intervals  of  relief. 
The  character  of  the  food  and  the  quantity  usually  have  a  bearing. 
Starchy  food  readily  produces  it,  and  a  light  meal  more  than  a  full  meal. 
The  latter,  when  rich  in  albumin,  often  causes  no  disturbance.  The  pain 
may  be  "a  dead  dull  pain,  with  a  gnawing  sensation,"  or  may  be  of  a  burn- 
ing character.  The  administration  of  an  alkali,  such  as  Vichy  or  sodium 
bicarbonate,  reheves  the  pain  by  neutralizing  the  acid;  or  milk,  raw  eggs, 
or  a  meat  sandwich,  by  binding  the  free  acid,  produces  the  same  result. 

2.  In  others  there  is  more  the  feeling  of  a  heat  or  burning  in  the  stom- 
ach or  the  feeling  of  a  sour  stomach. 

3.  Appetite  and  thirst  are  generally  normal. 

4.  No  cachexia. 

5.  Marked  constipation  is  the  rule. 

6.  Some  cases  are  quite  nervous  or  even  neurasthenic. 
Complications. — It  is  often  necessary  to  determine  whether  atony, 

dilatation  of  the  stomach,  or  gastroptosis  are  associated  with  the  hyper- 
chlorhydria. 

Simple  Atony. — Presence  of  the  splashing  sound  and  100  c.c.  or  more 
of  gastric  contents  aspirated  one  hour  or  more  after  Ewald's  test-breakfast; 
or  the  splash  with  the  presence  of  food  in  the  stomach  six  or  seven  hours 
after  the  test-meal;  the  lower  border  is  in  normal  position  as  determined 
by  the  splash  and  by  percussion. 

Dilatation. — Splash  at  the  umbilicus,  or  below  it,  shows  descent  of  lower 
border.  Percussion  alone  or  with  inflation,  or  gastrodiapbany  substan- 
tiate this  finding;  there  is  no  descent  of  the  upper  border.  Kidneys  are 
normal  in  position. 


376  DISEASES   OF  THE   STOMACH  AND  INTESTINES 

Gastroptosis. — Splash  at  the  umbilicus  or  below  it  shows  descent  of 
lower  border. 

Movable  kidney  is  diagnostic  if  found  in  addition.  There  is  diastasis 
of  the  recti  muscles;  inflation  or  gastrodiaphany  shows  descent  of  the  upper 
border  of  the  stomach  as  well  as  the  lower,  but  are  scarcely  necessary. 
The  x-rays  are  unnecessary  for  diagnosis,  but  determine  the  degree  with 
exactness,  the  presence  or  absence  of  complication  and  convince  the  patient. 

Differential  Diagnosis. — Acid  Gastritis. — Hyperacidity  is  present  plus 
abundant  stomach  mucus. 

Hypersecretion  {G astro siiccorr hea) . — ^The  stomach  in  the  fasting  condi- 
tion contains  75  to  100  c.c.  or  more  of  very  acid  gastric  juice.  The  per- 
sistent appearance  over  20  c.c.  to  30  c.c.  of  gastric  juice  in  the  fasting 
stomach  is  considered  pathognomonic  by  many.  Severe  attacks  of  pain 
and  vomiting  generally  occur  during  the  night  or  early  morning. 

Biliary  Colic. — Pains  are  later  (four  to  five  hours  after  meals)  or  inde- 
pendent of  meals.  The  pains  of  hyperchlorhydria  are  dependent  on  the 
meals.  Pains  of  biliary  colic  are  not  dependent  on  the  food,  are  not  re- 
lieved by  alkalis,  and  they  extend  over  the  right  epigastrium  and  hypo- 
chondrium,  and  frequently  to  the  right  shoulder  or  right  axillary  region. 
A  patient  with  biliary  colic  or  even  after  the  attack  has  no  appetite  and 
cannot  eat. 

The  appetite  is  good  in  hyperchlorhydria. 

The  gall-bladder  is  painful  on  pressure  and  at  times  swollen.  Icterus 
may  be  present.  Gall-stones  at  times  are  found  in  the  stool.  Leukocy- 
tosis is  present  in  biliary  colic  if  inflammation  is  associated.  Sometimes 
the  differential  diagnosis  is  difl&cult.  Gastric  analysis  may  be  necessary 
to  determine  it,  though  occasionally  both  conditions  occur  together.  The 
presence  of  Head's  gall-bladder  zone  may  aid  diagnosis. 

Ulcer  of  the  Stomach. — Epigastric  pain  is  intense,  appears  shortly  after 
the  ingestion  of  food;  local  tenderness  on  pressure  and  pain  increased  there- 
by. Pain  disappears  at  the  end  of  digestion.  Dorsal  pain  occurs  later, 
and  vomiting  in  many  cases  soon  after  meals. 

Hematemesis  occurs  or  occult  blood  is  found  in  the  gastric  contents  or 
stool.  Occult  blood  may  occur  with  gall-bladder  disease  in  the  gastric 
contents  of  achlorhydria  haemorrhagica  gastrica,  a  disease  of  peculiar 
characteristics  already  described,  and  not  particularly  difficult  of  diag- 
nosis. Ulcer  is  more  frequent  in  women.  The  discovery  of  occtdt  blood  is 
often  the  determining  factor  in  our  diagnosis  as  is  the  presence  of  micro- 
scopic pus  in  the  gastric  contents.^ 

Nervous  Gastralgia. — More  frequent  in  women  from  eighteen  to  thirty 
years.  Pain  appears  without  regularity,  and  is  in  no  way  dependent  upon 
the  meals,  or  character  of  food.  Is  relieved  by  pressure.  Intervals  of 
perfect  health;  nervous  temperament  always  present.  Gastric  analyses 
often  vary  in  the  same  case. 

Treatment. — The  treatment  comprises,  first,  the  removal  of  the  causes 
of  hyperchlorhydria;  and  second,  the  cure  of  the  condition  itself. 

Removal  of  the  Causes. — Interdict  tobacco  smoking  and  chewing.  If 
a  cigar  or  cigarette  holder  is  employed,  smoking  once  or  twice  a  day  I 
^  X-rays  may  be  required  to  determine  gastric  ulcer. 


FUNCTIONAL  DISEASES   OF  THE   STOMACH  377 

believe  may  be  harmless,  as  it  prevents  swallowing  saliva  impregnated 
with  tobacco  juice,  the  chief  source  of  irritation  in  my  opinion.  Alcohol 
in  every  form,  including  wines  and  beers,  should  be  prohibited.  All  kinds 
of  acids,  such  as  acetic,  tartaric,  or  citric,  should  be  forbidden;  and  all 
foods  prepared  with  them,  such  as  with  vinegar  or  lemon-juice;  and  all 
acid  or  acidulated  drinks.     Avoid  excess  of  salt. 

Condiments,  such  as  pepper,  ginger,  horseradish,  etc.,  pickles,  mustard, 
paprika,  nuts,  acid  fruits,  grapefruit,  and  radishes,  should  be  prohibited. 

Avoid  all  extremes  of  heat  and  cold  in  food  and  drink. 

Thorough  mastication  of  the  food  should  be  enjoined. 

Nervous  conditions,  when  present,  should  be  treated. 

Hygienic  regulations  are  important. 

Overwork  and  mental  anxiety  are  factors  in  the  production  of  hyper- 
chlorhydria.  Brokers,  professional,  and  business  men  must  be  relieved 
temporarily  from  overwork  and  worry  by  being  sent  into  the  country, 
where  various  open-air  amusements,  such  as  golf,  horseback  riding,  driv- 
ing, walking,  etc.,  can  be  indulged  in.  If  the  patient  have  a  taste  for 
fishing  or  shooting,  such  diversions  are  excellent.  I  have  seen  a  few  weeks 
in  camp  work  wonders. 

Those  indulging  in  a  continuous  round  of  social  festivities  should  be 
compelled  to  lead  a  quiet  life. 

On  the  other  hand,  there  are  many  people  of  wealth  with  no  occupa- 
tion whatever  who  become  entirely  self-centered  and  nervous  therefrom, 
and  for  such  a  class  of  persons  occupation  is  of  great  value. 

Hydrotherapy,  such  as  sponge-baths,  douches,  etc.;  also  a  moderate 
indulgence  in  calisthenics  (ten  minutes  morning  and  night). 

For  the  cure  of  the  hyperchlorhydria  there  are  practically  two  methods 
used,  alone  or  in  combination: 

We  may  bind  the  excess  of  free  hydrochloric  acid  by  the  administra- 
tion of  large  quantities  of  proteins,  or  we  may  neutralize  the  excessive  acid 
by  the  administration  of  an  alkali.  Clinical  observation  has  demonstrated 
that  those  articles  of  food  which  are  capable  of  binding  large  quantities 
of  HCl  are  borne  the  best.  The  burning  feeling  of  distress  or  pain  is 
relieved  by  the  administration  of  albuminous  food.  Carbohydrates,  if  given 
in  any  quantity,  cause  distress.  The  diet  is,  therefore,  of  greatest 
importance. 

Diet  in  Hyperchlorhydria. — As  noted  under  Prophylaxis,  all  articles 
which  are  liable  to  overstimulate  the  secretory  glands  of  the  stomach 
should  be  forbidden.  Among  such  are  acids,  all  spices,  as  pepper  and 
mustard,  pickles,  horseradish,  olives,  acid  fruits,  beers,  and  wines.  Salt 
should  be  diminished. 

The  food  should  be  rich  in  albumin,  such  as  chops,  steak,  roast  beef, 
mutton,  game,  eggs,  milk,  oysters,  and  fish.  Bread  and  butter  can  be 
taken,  the  former  in  moderation.  Green  vegetables,  such  as  spinach, 
asparagus,  lettuce,  peas  and  string  beans,  potatoes,  rice,  and  other  cereals, 
should  be  given  in  small  quantity.  They  should  be  taken  in  combination 
with  large  amounts  of  albuminous  food.  The  writer  finds  that  some  cases 
of  hyperchlorhydria  complain  that  milk  does  not  agree.     The  addition  of 


378  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

a  small  dose  of  sodium  citrate  to  each  glass  of  milk  will  often  obviate  this 
difficulty. 

Alcohol  in  all  forms,  including  beers  and  wines,  I  believe  should  be 
avoided,  also  coffee;  though  some  allow  a  small  amount  of  beer  and  very- 
weak  cofifee.  Fleiner  has  demonstrated  that  egg-albumen  binds  more  free 
hydrochloric  acid  than  any  other  food.  Among  other  articles  especially 
suitable  for  this  purpose  he  recommends  boiled  veal,  beef,  mutton,  raw 
ham,  Leube-Rosenthal's  beef  solution,  boiled  ham,  boiled  pork,  Swiss 
cheese,  Roquefort,  pumpernickel,  milk,  and  cocoa. 

In  my  own  experience  I  have  found  gelatin^  an  excellent  remedy, 
employing  i  or  2,  or  even  3  ounces  of  a  5  to  10  per  cent,  gelatin  solution, 
flavored  with  a  pinch  of  sugar  or  a  little  vanilla,  and  given  midway  be- 
tween meals.  The  value  of  egg-albumen  and  cocoa  is  marked.  Starchy 
foods  that  have  been  well  dextrinized,  such  as  zwieback  and  toast,  subse- 
quently dried  in  the  oven,  are  more  readily  digested. 

Strauss  has  shown  that  if  carbohydrates  are  introduced  in  the  form  of 
sugars  in  solution  they  do  not  markedly  increase  HCl  secretion.  He  gives 
200  to  300  c.c.  of  a  20  per  cent,  dextrose  solution  during  the  day. 

Considerable  water  should  be  taken  during  meals,  or  Appollinaris  and 
seltzer,  if  no  atony  is  present.  A.  Schmidt  uses  a  mixed  diet  and  advises 
that  all  foods  should  be  well  cooked  and  carefully  minced.  He  recom- 
mends that  the  stomach  should  come  to  rest  at  least  once  in  twenty-four 
hours  and  gives  a  large  quantity  of  food  in  the  morning,  but  small  amounts 
at  night.  In  the  forenoon,  two  to  three  meals  at  two-hour  intervals  so 
there  is  little  appetite  for  lunch;  thereafter  no  food  until  7  p.  m.  and  then 
only  porridge.  He  allows  no  sparkling  waters  and  diminishes  fluid,  re- 
stricting it  to  hours  when  the  stomach  is  not  filled  with  food.  He  gives 
the  meals  rather  dry  except  at  breakfast  and  the  evening  soup  and  has 
the  patients  drink  a  short  time  before  lunch  or  in  the  afternoon.  If  the 
condition  is  severe  the  patients  have  to  remain  in  bed  several  weeks. 
Hot  compresses  are  applied  twice  daily  for  two  hours. 

Fats,  such  as  butter  and  cream,  are  of  value.  Since  the  carbohydrates 
are  restricted  and  additional  calories  must  be  secured,  Strauss,  Ewald, 
and  others  advise  their  use.  Furthermore,  fats  lessen  the  acidity,  also 
possibly  the  irritable  tendency  of  the  mucous  membrane.  Cream  has 
been  thus  recommended. 

For  some  years  I  have  been  accustomed  to  administer  olive  oil  once  or 
even  three  times  daily  before  meals  in  obstinate  cases  of  hyperchlorhydria, 
using  from  H  to  i  ounce  (15.0-30.0),  suspended  in  water.  This  has 
lessened  the  hyperacidity.  In  the  same  way,  glycerin,  K  to  2  drams  (2.0- 
8.0),  mixed  in  water,  may  be  used.  lUoway^  employed  it  in  one  case. 
Almond  oil  is  also  of  value. 

If  we  attempt  to  treat  h3^erchlorhydria  by  diet  alone,  we  should  give 
three  additional  feedings  at  a  time  after  the  regular  three  meals,  such  as 
would  bind  the  excessive  hydrochloric  acid  and  prevent  the  symptoms. 
The  extra  feedings  may  consist  of  koumiss,  matzoon  and  Vichy,  bacillac, 
bouillon,  a  sandwich,  milk,  raw  eggs  (especially  the  whites)  and  milk,  with 

^  Calves'  foot  and  chicken  jellies  are  excellent. 

*  N.  Y.  Med.  Jour.,  3Iay  25,  June  i,  15,  and  29,  1901. 


FUNCTIONAL  DISEASES   OF  THE    STOMACH  379 

crackers  or  bread  and  butter.     One  can  select  a  diet  from  the  tables  with  a 
sufficient  number  of  calories.  ' 

For  practical  purposes  an  improvement  in  nutrition — i.e.,  some  increase 
in  weight — should  be  secured,  even  though  slight,  in  addition  to  the  amelio- 
ration of  symptoms.  This  refers  only  to  those  of  thin  habit,  not  to  the 
well  nourished.  The  use  of  the  scales,  weighing  at  stated  intervals,  is  of 
radical  importance.  Assimilation  differs  in  individual  cases,  and  though 
on  paper,  the  calories  may  be  correct,  a  loss  of  weight  shows  a  radical  error 
in  the  treatment.  The  following  is  a  sample  dietary,  such  as  is  usually 
recommended  for  a  patient  of  good  physique  and  quite  active.  The  con- 
tent of  protein  is  very  high  as  compared  with  Chittenden's  scale,  which  I 
advocate  in  health.  It  is  frequently  advisable  to  diminish  the  quantity 
of  meat  and  substitute  milk,  matzoon,  koumiss,  or  bacillac.  Lactone- 
buttermilk  is  also  excellent.  Gelatin  solutions  bind  the  free  hydrochloric 
acid  in  a  satisfactory  manner.  Depending  on  the  normal  weight,  height, 
and  occupation,  the  diet  must  be  formulated  in  every  case: 

Calories 

7.30  A.  M. — 250  c.c.  milk,  cocoa,  2  eggs,  3  zwieback,  and  butter 

(20  grams) 690 

10.30  A.  M. — 200  c.c.  milk,  with  i  raw  egg,  or  matzoon  and  Vichy 
125  c.c,  or  koumiss  250  c.c,  or  milk  250  c.c,  or 

bouillon  with  i  raw  egg  (approximately) 240 

Bread  2  slices,  or  cracker  2  oz.  (gm.  60) 160 

Butter  gm.,   20,   water,  or  Appollinaris,  or  Vichy  250 

c.c,  occasionally  weak  tea 163 

1.30  p.  M. — Chops,  steak,  beef,  or  mutton,  100  gm.  (about) 200 

Mashed  potatoes,  30  gm 37 

Spinach,  30  gm 12 

Bread  (i  slice),  30  gm 81 

Butter,  10  gm 80 

4.30  P.  M. — Same  as  at  10 .  30  A.  M 563 

7.00  p.  M. — Soup  (barley),  200  c.c 100 

Meat,  broiled  100  gm 200 

Spinach  or  peas,  50  gm 30 

Potatoes  mashed  with  milk,  50  gm 80 

Weak  tea,  100  c.c  (three-fourths  milk) 64 

Toast  (i  slice) 75 

Butter,  10  gm 81 

10.00  p.  M. — Milk  and  Vichy,  aa  100  c.c 64 

Total  calories 2920 

Various  modifications  may  be  made. 

Coffee  I  interdict.  All  fried  food  should  be  forbidden,  as  should  hot 
breads,  fresh  bread,  hot  biscuits,  acid  fruits,  acids,  highly  spiced  food, 
pastry,  and  rich  desserts.  The  food  should  not  be  excessively  hot  or  cold. 
The  patient  should  eat  slowly,  masticate  thoroughly,  and  rest  after  eating 
for  at  least  twenty  minutes  to  one-half  hour. 

Illoway  and  Bouveret  advocate  only  three  meals  a  day,  with  a  sandwich 
at  bedtime  in  some  cases.  They  believe  the  stomach  should  have  an 
interval  of  rest  so  as  to  become  perfectly  emptied.  Practically,  Illoway's 
only  medication  is  one-half  glass  of  French  Vichy,  given  at  10  to  11  A.  m., 
at  4  to  5  p.  M.,  and  at  night,  if  the  sandwich  is  omitted. 


380  DISEASES   OF   THE    STOMACH   AND  INTESTINES 

They  believe  that  unless  the  stomach  have  some  rest,  atony  or  atonic 
dilatation  may  result^ 

On  the  other  hand,  some  patients  can  only  eat  a  small  amount  of  food 
at  a  time,  have  the  desire  to  eat  at  frequent  intervals,  and  feel  better  if  they 
do  so.  Repeated  feedings  are  difl&cult  to  follow  out  in  some  cases,  so 
conditions  vary. 

My  method  is  to  give  the  three  regular  meals  a  day  with  diminished 
carbohydrates,  with  the  alkalis  an  hour  to  an  hour  and  a  half  or  even  two 
hours  later.  If  it  is  necessary  to  improve  nutrition,  additional  feedings 
are  given,  a  glass  of  koumiss,  or  milk  and  raw  egg,  or  matzoon  and  Vichy, 
or  I  to  2  ounces  of  10  per  cent,  gelatin  solution  (sweetened)  between  meals 
or  if  pain  comes  on  after  the  administration  of  the  alkali.  These  foods 
can  be  alternated. 

Medication. — Among  the  alkalis  that  are  of  value  are  Vichy,  imported 
or  siphon,  bicarbonate  of  soda,  milk  of  magnesia  (Phillips),  magnesia  usta, 
magnesia  ammoniophosphorica,  and  biborate  of  soda  (Jaworski). 

A  little  sugar  of  milk  can  be  added  to  the  soda  or  magnesia  prepara- 
tions to  make  them  more  agreeable.  If  the  hyperchlorhydria  is  compli- 
cated by  atony,  then  bicarbonate  of  soda  (which  generates  considerable 
carbonic  acid  gas)  would  be  objectionable. 

The  following  rule  should  be  carried  out  as  regards  the  administration 
of  the  alkalis:  "Give  them  in  ample  time  to  anticipate  the  appearance 
of  symptoms  by  a  considerable  margin."  They  should  be  administered 
t.i.d.  after  meals,  depending  upon  the  time  of  appearance  of  symptoms. 
Repeat  the  dose  if  the  symptoms  begin  later,  unless  albuminous  food  is 
given  as  a  substitute. 

The  magnesia  preparations  have  the  tendency  to  move  the  bowels  and 
hence  are  of  special  value.  If  the  result  is  too  active,  combine  the  mag- 
nesia with  varying  porportions  of  soda  bicarbonate,  or  give  the  latter 
alone,  or  give  bismuth  subnitrate  with  the  magnesia.  Magnesia  usta 
will  neutralize  about  four  times  more  acid  than  soda  bicarbonate. 

The  dosages  are  as  follows,  given  from  one  to  two  hours  after  meals 
t.i.d.: 

Vichy 175  to  250  c.c.  (H-i  glassful). 

Vichy H    to  i  glassful  plus  sod.  bicarb.  ^  to  i 

teaspoonful  (2.0-4.0).  Allow  this  to 
become  flat  (effervescence  to  disappear). 

Sod.  bicarb I'i  to  i   (2.0-4.0)  teaspoonful  in  one-third 

glassful  of  water. 

I^.  Magnesia  usta) ^.g  ^^ 

Sod.  bicar.        j 
Dose,  y2  to  I  teaspoonful  (2.0-4.0)  in  water  t.i.d. 
A  little  sugar  of  milk  or  i  minim  of  oil  of  peppermint  may  be  added 

to  flavor. 
If  the  bowels  move  too  freely,  diminish  magnesia,  then  give: 

I^.  Magnesia  usta 5ss  (16.0); 

Sod.  bicarb q.  s.  5ij  (64.0). — M. 

Dose,  H  to  I  teaspoonful  (2.0-4.0)  in  water. 

If  necessary,  bismuth  subnitrate,  2  drams  to  J-^  ounce  (8.0-16.0),  may 
be  added  to  the  above  combination. 


FUNCTIONAL  DISEASES   OF  THE   STOMACH  38 1 

I^.  Sod.  bicarb 5j  (32.0); 

Magnesia  usta gss  (16.0); 

Magnesia  ammon.  phos 5ss  (16.0). — M. 

Dose,  Vi  to  I  (2.0-4.0)  teaspoonful  in  water. 

I^.  Magnesia  usta. .  •. 5ss  (16.0); 

Pulv.  rhub '. gm.  xv  (i.o); 

Soda  bicarb 5ss  (16.0); 

Sugar  of  milk 5ss  (16.0). — M, 

Dose,  Vi  teaspoonful  (2.0)  in  water  if  costive,  or, 

Milk  of  magnesia   (Phillips) 5j  toiv  (4.0-16.0),  in  water  t.i.d. 

This  last  I  have  found  to  be  an  excellent  preparation,  especially  where 
constipation  is  marked.  It  is  one  of  the  most  serviceable  remedies  for 
hyperchlorhydria. 

Adolf  Schmidt  :i 

I^.  Magnes.  oxid 5ss; 

Ext.  bellad gr.  Hi 

Sod.  sulph 3ss; 

One  dose  t.i.d.  p.  c.  particularly  if  costive. 

Powdered  charcoal,  kaolin  and  aluminum  silicate  have  been  suggested 
as  an  acid  binder  by  mechanical  absorption. 

Winternitz  employs  magnesium  peroxid  3ss  t.i.d.  having  observed 
that  small  quantities  of  hydrogen  peroxid  diminish  pronouncedly  the  acid- 
ity of  the  gastric  contents. 

Peroxid  of  hydrogen  was  recommended  by  Petri  in  large  amounts, 
300  ex.  of  a  o.  5  solution  on  an  empty  stomach,  but  was  found  to  produce 
nausea.  Giving  it  in  almond  water  lessens  this  objection.  It  should  be 
given  in  smaller  dosage  and  only  for  long  periods  as  its  prolonged  use  is 
apt  to  cause  catarrh. 

Sod.  biborate gr.  x  to  xv  (0.6-1.0), 

in  water  (J^worski), 

has  been  recommended. 

The  use  of  Carlsbad  water  or  a  glass  of  the  imported  Carlsbad  salts,  1 
to  2  drams  (4.0-8.0)  in  warm  water  on  rising,  lessens  acidity  and  helps 
the  bowels. 

Wolff's  artificial  Carlsbad  mixture  consists  of: 

I^.  Sod.  sulph 30.0; 

Sulph.  potass 5.0; 

Sod.  chlorid 30-o; 

Sod.  carb 7S-o; 

Sod.  biborate lo.o. — M. 

He  adds  sod.  biborate  on  account  of  Jaworski's  recommendation. 
Dose,  Vi  dram   (2.0)   in  one-half  glassful  of  warm   water  two  hours 
before  meals. 

In  some  cases  I  give  olive  oil,  ^  to  i  ounce  (15.0-30.0)  or  more,  or 
glycerin,  J-^  to  2  drams  (2.0-8.0),  in  a  little  water  before  meals,  to  lessen 
gastric  irritability;  bismuth  subnitrate,  15  grains  to  H  dram  (1.0-2.0), 
given  with  the  olive  oil,  is  often  useful. 

1  Journal  A.  M.  A.,  Feb.  17,  1914. 


382  DISEASES   OF   THE   STOMACH  AND  INTESTINES 

If  the  pain  is  severe,  the  administration  of  belladonna  before  secretion 
commences,  in  order  to  lessen  the  gastric  juice,  is  of  value.  At  the  time  of 
pain  it  is  too  late.  It  is  serviceable  also  in  marked  or  obstinate  cases 
to  lessen  Hcl,  thus  before  meals: 

I^.  Tinct.  belladonna 3iss  (6.0); 

Aq.  destil q.  s.  3ij  (60.0). — M. 

Dose,  H  to  I  teaspoonful  (2.0-4.0),  or  larger  dose  of  tinct.  belladonna, 
up  to   10  drops,  may  be  given,  t.i.d.  15  minutes  to  half  hour  be- 
fore meals. 
or 

Ext.  belladonna gr.  H  to  H  (00.1-0.02). 

or 

Atropin gr.  Moo  (0.0006)  or  Ho  (0.0012) 

lUoway  suggests: 

I^.  Tinct.  aconite  root 6  drops; 

Tinct.  belladonna 25  drops; 

Aq.  destil q.  s.  5]  (30.0). — M. 

Dose,  I  teaspoonful  (4.0)  on  rising  and  a  second  dose  in  half  an  hour. 
No  more. 

If  the  pain  is  extremely  severe  and  not  relieved  by  an  alkali  or  bella- 
donna, hyoscyamin  hydrobromate  gr.  1^00  t.i.d.  before  meals  should  be 
tried.  A  small  dose  of  codein,  M  to  3^  grain  (0.008-0.016),  may  be  re- 
quired. This  may  even  be  given  by  hypodermic  with  excellent  results. 
Morphin  in  same  dosage  is  rarely  necessary  and  should  only  be  given  by 
the  physician. 

The  application  of  heat  to  the  epigastrium  by  moist  compresses,  hot- 
water  bag,  or  poultice  is  of  service. 

If  the  patient  is  very  restless  and  disturbed,  one  of  the  bromids — 
strontium  bromid,  sodium  bromid,  or  ammonium  bromid— may  be  given 
in  10-  to  15-grain  (0.06-1.0)  doses  for  a  brief  period,  t.i.d. 

In  obstinate  cases,  silver  nitrate,  K  to  3^  grain  (0.008-0.016)  t.i.d., 
or  in  solution,  has  been  recommended  to  relieve  gastric  secretion,  or  occa- 
sionally a  douche  or  spray  with  silver  nitrate  (i  :  2000)  followed  by  lavage 
with  water  or  argyrol  or  protargol  i  :25oo  by  lavage.  If  the  douche  is 
used,  lavage  is  unnecessary  unless  there  is  a  complicating  atonic  dilatation. 
If  one  sees  the  patient  during  a  severe  attack  of  pain,  aromatic  spirits  of 
ammonia,  }i  to  i  dram  (2.0-4.0),  diluted  well  with  water;  lime-water,  i 
to  2  ounces  (30.0-60.0),  mistura  cretae,  K  to  i  ounce  (15.0-30.0),  or  bi- 
carbonate of  soda  or  the  magnesia  preparations  can  be  given  at  once,  with 
belladonna  10  drops,  or  atropine  Hoo^Ho- 

Sometimes  sodium  bicarbonate  distends  the  stomach  and  causes  more 
pain.  Emesis  is  often  a  relief,  and  at  times,  when  other  treatment  fails, 
lavage  may  be  used  as  a  temporary  method. 

Electricity  has  been  recommended,  especially  by  Einhorn,  for  the  treat- 
ment of  hyperacidity. 

Internal  galvanization  has  been  suggested  for  the  relief  of  pain. 
It  seems  to  be  impractical. 

In  cases  when  constipation  is  obstinate  or  when  atony  is  present,  it 
might  be  of  service,  either  the  intragastric  or,  preferably,  the  percutaneous 
method  of  faradization. 


FUNCTIONAL   DISEASES    OF    THE    STOMACH  ^St, 

Bowels. — Massage,  vibratory  massage,  and  rectal  injections  of  olive 
oil  are  of  service,  as  well  as  out-of-door  exercise,  horseback  riding,  etc. 
Remedies  such  as  cascara,  aloes,  phenolax,  purgen,  regulin,  the  mineral 
oils,  olive  oil,  etc.,  may  be  at  times  temporarily  necessary. 

If  there  are  atony,  dilatation,  or  ulcer,  these  conditions  must  be  treated. 
Rose's  belt  is  indicated  for  atony  or  atonic  ectasia. 

To  briefly  recapitulate.     I  have  found  the  following  of  value: 

Carlsbad  salts  on  rising,  though  not  always  required. 

Milk  of  magnesia  (Phillips)  or  magnesia  usta,  alone  or  with  soda  bicar- 
bonate, or  Vichy  and  soda  bicarbonate,  one  to  two  hours  after  meals; 
midway  between  the  chief  meals  a  little  milk  and  raw  eggs,  koumiss,  mat- 
zoon,  and  Vichy,  or  i  to  2  ounces  (30.0-60.0)  of  gelatin  solution  (5  to  10 
per  cent.). 

In  some  cases  olive  oil  before  meals  t.i.d.  with  belladonna  extract  gr. 
}4  or  tincture  5-10  drops,  preferably. 

The  proper  diet  must  be  followed. 

HYPOCHLORHYDRIA  AND  ACHLORHYDRIA 

These  functional  disturbances  of  the  stomach  may  be  associated  with 
organic  disease  of  this  organ,  may  be  a  reflex  from  some  other  disease,  may 
occur  with  a  constitutional  disease  such  as  syphilis  or  arteriosclerosis,  may 
be  associated  with  nervous  disease,  or  result  from  a  general  depression  of 
the  entire  system  such  as  due  to  overwork  or  from  sympatheticotonia 
or  rarely  may  be  a  neurosis.  Achlorhydria  (absence  of  hydrochloric  acid) 
is  a  progressive  stage  of  hypochlorhydria.  Unfortunately  there  is  a  tend- 
ency among  some  of  our  gastrologists  to  confuse  achylia  gastrica  and 
achlorhydria.  With  the  former  the  acidity  is  low,  4-f-  to  6-+-,  HCl  is 
absent,  as  are  also  pepsin  and  rennet.  With  achlorhydria  HCl  is  absent, 
the  ferments  are  present  and  total  acidity  is  higher,  and  also  mucus  is 
present  only  if  there  is  catarrh  in  addition. 

Under  normal  conditions  free  hydrochloric  acid  averages  25-!-  to  50+. 
With  free  hydrochloric  acid  on  an  average  20+  or  less  we  may  consider  it 
a  hypochlorhydria  if  gastric  symptoms  are  present. 

Etiology. — Hypochlorhydria,  or  achlorhydria  have  been  found  in 
association  with  the  following:  gastric  cancer,  gastric  ulcer,  achlorhydria 
haemorrhagica  gastrica,  chronic  gastritis,  gastroptosis,  visceral  arterio- 
sclerosis, syphilis  or  the  gastric  crises  of  locomotor  ataxia,  chronic  erosions, 
atonic  dilatation  of  the  stomach,  acute  gastritis  or  reflex  from  disease  of 
some  other  organ  such  as  from  gall-bladder  disease,  chronic  appendicitis, 
chronic  pancreatitis,  or  with  cancer  of  the  breast  or  uterus  without  in- 
volvement of  the  stomach,  Sympatheticotonia  may  be  a  factor.  Neu- 
rasthenics or  patients  of  nervous  type  may  suffer  from  these  conditions 
and  those  who  have  overworked,  or  have  been  undergoing  severe  mental 
strain  may  have  these  derangements.  Rarely  hypochlorhydria  or  achlor-. 
hydria  may  be  a  neurosis. 

In  4937  cases  with  stomach  disturbances,  Kelling^  found,  excluding 
ulcer,  every  seventh  man  and  fifth  woman  had  no  free  HCl.  No  free  HCl 
1  Archiv  fiir  Verdamingskr.,  Oct.,  1909. 


384  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

was  found  in  30  per  cent,  of  gall-stones,  and  in  30-40  per  cent,  of  diabetes, 
gout,  renal  calculus  and  tuberculosis. 

The  author  cites  a  few  cases  of  various  types. 

Case  i. — Stomach  in  normal  position.  Patient  a  priest  of  nervous  tem- 
perament, aged  fifty-two,  has  been  very  active  mentally  with  sedentary 
life.  Is  obese.  For  a  few  months  pain  half  an  hour  after  meals,  gas  and 
eructation. 

Achlorhydria. — Improved  rapidly  under  diet,  exercise,  hydrochloric 
acid,  triple  valerian  pills,  etc. 

Case  2. — Stomach  in  normal  position.  Priest,  aged  forty-seven. 
Sister  had  urticaria.  No  history  of  asthma.  Has  had  gastric  trouble 
for  some  years.  Some  time  ago  hydrochloric  acid  was  found  to  be 
deficient  by  another  physician.  His  first  visit  to  the  writer  was  on 
Jan.  13,  1915.  He  had  marked  urticaria  with  which  he  had  been 
continuously  afflicted  for  two  months,  and  had  suffered  considerably  there- 
from. He  had  three  attacks  of  angioneurotic  edema  within  six  weeks, 
affecting  the  left  side  of  the  face  and  lower  lip,  the  last  attack,  Jan.  11, 
191 5,  two  days  before  his  visit  to  me.  With  his  first  attack  there  was 
hoarseness,  evidently  edema  of  the  glottis.  He  traced  one  of  these 
attacks  apparently  following  eating  of  a  large  steak.  The  urticaria  at  the 
time  became  worse. 

His  gastric  analysis  showed  total  acidity  i6-f,  free  HCl  8-f-,  comb.  HCl 
8+;  hypochlorhydria.  Urine  showed  a  trace  of  indican  and  trace  of  ace- 
tone. With  deficient  protein  digestion,  and  the  history,  the  case  was 
evidently  one  of  protein  absorption  with  anaphylaxis,  resulting  in  urticaria 
and  angioneurotic  edema. 

Treatment  was  begun  with  elimination  of  red  meat  and  cutting  down 
proteids,  oxyntin  (powdered  HCl)  with  nux,  hexamethylenamine,  gr.  v, 
t.i.d.  and  phosphate  soda  5i  A.  M. ' 

Jan.  16,  1915,  urticaria  had  disappeared  entirely,  later,  Feb.  19,  1915, 
a  mild  attack  recurred.  At  the  present  time,  though  the  achlorhydria 
still  persists  (May  25,  1916),  the  patient  is  in  excellent  condition  and  has 
no  further  attacks  of  urticaria  or  angioneurotic  edema.     Diet  is  rigid. 

Case  3. — Infantilism.  Chronic  intestinal  putrefaction,  hypochlorhy- 
dria, convulsions.    Patient  sent  in  consultation  by  Dr.  Denis  of  Jersey  City. 

Boy,  aged  four  and  one-half,  artificially  fed,  has  convulsions  off  and  on 
since  eight  months  of  age,  and  of  late  every  month  or  two  had  convulsive 
seizures.  His  weight  when  the  author  first  examined  him,  Jan.  2,  1912, 
was  only  22  pounds,  the  child  was  fairly  bright  but  physically  undevel- 
oped, with  a  pot  belly.  He  also  had  attacks  of  vomiting.  The  lower 
border  of  the  stomach  reached  the  umbilicus  (dilatation). 

Gastric  analysis.  Total  acidity  3o-F;  free  HCl  o;  comb.  HCl  20+; 
lactic  and  inorganic  acids.  Since  there  was  sufficient  HCl  to  give  2o-|- 
comb.,  though  no  free  HCl,  it  should  be  considered  hypochlorhydria,  and 
not  achlorhydria.  Indican  and  oxalates  were  in  very  large  amount,  urea 
3.09.  The  stool  showed  large  numbers  of  gram-positive  organisms  such  as 
are  described  by  the  late  Christian  Herter  in  his  brochure  on  infantilism. 

There  was  marked  secondary  anemia.  By  Jan.  6  all  reports  secured. 
Jan.  2,   1912,  the  diet  advised  was  well-boiled  rice,  arrow-root  gruel. 


I  .  30  p.  M. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH  385 

cream  of  wheat,  Huntley  and  Palmer  breakfast  biscuit,  milk  sugar, 
avoiding  malted  milk,  Mellen's  food  and  potatoes;  Cox's  gelatin  5i  daily 
in  jelly  form,  chicken  jelly,  rice  flour  gruel,  milk,  spinach,  beef,  chicken  or 
mutton  broth,  beef  juice  from  i  pound  of  rump.  No  meat.  Total  milk 
18  ounces  daily,  the  diet  advocated  by  the  late  Dr.^erter. 

Huntley  and  Palmer,  6  biscuits  daily. 

Gelatin  5i  daily. 

Beef,  chicken  or  mutton  broth  5  vi  daily. 

Rice  5i  daily. 

Beef-juice  from  i  pound  rump  daily. 

The  feedings  were  arranged  as  follows: 

I  Milk  gviwith  gelatin  (jelly),  one  Huntley  and  Palmer 
'■         *     ■        1      biscuit. 

9 .  30  A.  M.  Milk  5  vi  with  gelatin,  Huntley  and  Palmers,  two. 

Beef  juice,  5ss-5i. 
Spinach,  5ss. 
Rice,  5ss. 

Huntley  and  Palmer,  one 
4.30  p.  M.  Variety  of  broth  5^  with  gelatin. 

[  Rice  5  ss. 
6 .  30  p.  M.        I  Milk  5  vi  with  gelatin. 

I  Huntley  and  Palmers,  two. 

Medication. — 1  aka-diastase  gr.  3  to  5  t.i.d.,  mixed  with  food,  lacto- 
bacillin  tablet  one  t.i.d.,  iron  tropon  one  t.i.d.,  lactate  calcium  gr.  i  to 
2  t.i.d.    Acet ozone  enema  Hooo  i  pint  to  iH  pints  (high)  daily. 

Feb.  24,  191 2. — 37  pounds,  gain  15  pounds  in  seven  weeks,  no  convul- 
sions. 

Dec.  2,  191 2. — Weight  48  pounds,  only  one  convulsion  since  previous 
to  Jan.  6,  191 2,  due  to  stopping  out  a  day  or  two. 

Jan.  6,  1913. — Weight  52  pounds,  normal  stool,  still  some  excess  of 
indican,  but  much  less  than  one  year  ago,  oxalates  normal,  urea  now  low 
and  chlorides  high. 

Subsequently  by  June,  1913,  the  patient's  weight  increased  to  58 
pounds  as  reported  to  me.  He  later  had  an  attack  of  diphtheria  and 
lost  some  weight,  having  subsequently  had  two  convulsions,  but  no  others 
followed  for  a  year.  On  May  18,  1916,  the  boy  reported  to  me.  He  has 
had  no  convulsions  for  two  years.  His  mother  states  that  he  is  now 
extremely  active  and  for  a  year  has  acted  like  a  normal  boy.  He  is  very 
small,  weight  only  53  pounds,  less  than  in  1913.  He  is  bright  in  his  studies. 
The  pot  belly  has  disappeared  and  the  stomach  is  in  normal  position. 
The  diet  has  now  been  amplified  into  a  greater  variety,  but  still  with 
avoidance  of  red  meat  and  excess  in  proteids. 

Case  4. — Male,  aged  fifty-eight.  163  gall-stones  removed  two  years 
previously.  In  July,  1914,  abdominal  distress — loose  stools  of  putty 
color — no  nausea,  tongue  coated,  belching. 

Physical  Examination. — Tenderness  at  Robson's  point,  some  soreness  in 
epigastrium,  sensitive  at  Morris  and  McBurney's  points,  gall-bladder 
slightly  sensitive,  secondary  anemia. 

25 


386  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Radiograph  shows  dilated  duodenum  from  adhesions.  Gastric 
analyses.     Total  acidity  17+ ;  free  HCl  o;  comb.  HCl  12,  trace,  lactic  acid. 

Urine. — Indican,  faint  trace,  no  bile.  Stool,  excess  of  unabsorbed  free 
fats,  partly  digested  meat  and  excess  of  soaps. 

Diagnosis. — By  the  writer,  gall-stones,  cholecystitis,  chronic  pancreati- 
tis, chronic  appendicitis,  adhesions,  with  hypochlorhydria  (or  achlorhydria^ 
as  to  free  acid).  All  were  confirmed  at  operation  by  John  Erdmann,  who 
removed  the  appendix  and  an  infected  gall-bladder  containing  calculi. 
The  chronic  pancreatitis  and  adhesions  were  present.  The  latter  were 
separated.  The  hypochlorhydria  was  evidently  reflex.  Subsequent  to 
operation,  the  diarrhea  and  putty  stools  disappeared  and  the  patient  has 
greatly  improved,  having  gained  some  weight. 

In  general  with  hypochlorhydria  we  have  the  following  symptoms: 
These  may  be  gastric,  with  belching,  pain,  discomfort  after  food,  suggestive 
of  chronic  gastritis,  or  they  may  be  nervous  chiefly  with  intestinal  toxemia. 

Treatment. — The  diet  would  be  much  the  same  as  with  chronic  gas- 
tritis, less  meat  and  more  carbohydrates.  Hydrochloric  acid,  or  in  the 
form  of  oxyntin  would  be  indicated,  also  strychnin  or  nux  vomica,  and  the 
treatment  of  indicanuria  if  present,  nerve  tonics  should  be  given  in  the 
nervous,  or  neurasthenic  cases.  Gastroptosis  should  be  corrected  if  in 
evidence.  If  the  condition  is  reflex,  or  associated  with  organic  disease  of 
the  stomach,  the  cause  must  receive  treatment.  If  sympatheticotonia  is 
a  factor,  it  should  be  treated. 

GASTROSUCCORRHEA  (CONTINUOUS  SECRETION  OF  GASTRIC  JUICE) 
{Synonyms. — Hypersecretion;  Parasecretion ;  Excessive  Flow  of  Gastric  Juice;  Reich - 
mann's  Disease;  Gastroxynsis — Rossbach) 

Gastrosuccorrhea  is  a  perversion  of  function  in  which  the  glands  of 
the  stomach  secrete  large  quantities  of  gastric  juice  even  when  the  stomach 
is  empty,  and  hence  when  there  is  no  irritation  from  ingested  food.  The 
diagnosis  rests  on  the  removal  from  the  stomach  in  the  fasting  condition 
of  a  considerable  quantity  of  gastric  juice,  with  the  addition  of  symptoms 
which  present  a  characteristic  picture.  To  Reichmann  the  credit  is  due 
of  having  first  called  attention  to  this  perversion  of  function. 

Gastrosuccorrhea  may  be  classified  in  two  types: 

1.  Gastrosuccorrhea  continua  periodica  or  the  intermittent  form  of 
hypersecretion;  the  attacks  occur  at  irregular  intervals. 

2.  Gastrosuccorrhea  continua  chronica  or  chronic  hypersecretion. 
Though  some  believe  that  hypersecretion  is  a  purely  secretory  neurosis, 

other  factors  can  also  produce  it.  Unquestionably,  nervous  conditions, 
such  as  mental  excitement  or  mental  overexertion,  may  be  the  direct  cause 
in  some  cases;  hence,  gastrosuccorrhea  may  be  a  pure  neurosis. 

On  the  other  hand,  direct  irritation  of  the  mucous  membrane  can  be  the 
cause;  in  fact,  the  same  factors  that  produce  hyperchlorhydria,  such  as 
rapid  eating,  indigestible  food,  spices  and  condiments,  abuse  of  alcohol, 
bolting  the  food,  excessively  hot  or  cold  food  or  drink,  etc. 

^Noting  the  HCl  o,  Erdmann  feared  the  possibility  of  malignancy  of  the  pancreas. 
The  author  has  observed,  however,  that  with  marked  chronic  pancreatitis  HCl  is  much 
diminished,  or  absent,  while  with  an  incipient  case,  as  reported  under  chronic  pan- 
creatitis there  may  even  be  hyperchlorhydria. 


FUNCTIONAL   DISEASES    OF    THE    STOMACH  387 

Hyperchlorhydria  of  long  standing,  especially  if  neglected,  may  be  a 
factor  in  the  ultimate  production  of  continuous  secretion.  In  some 
of  the  gastric  crises  of  locomotor  ataxia,  gastrosuccorrhea  is  at  times 
observed. 

Hypersecretion  is  also  at  times  an  accompaniment  of  dilatation  of  the 
stomach,  either  of  the  atonic  type  or,  more  frequently,  in  the  form  due  to 
stenosis  of  the  pylorus.  It  also  may  occur  with  ulcer  of  the  stomach  or 
duodenum.  It  can  even  accompany  acute  dilatation  of  the  stomach, 
especially  in  that  form  engrafted  on  a  chronic  stenotic  dilatation,  to 
which  I  refer  under  Acute  Ectasy.  It  at  times  is  caused  by  vagotonia. 
Tetany  may  be  rarely  associated. 

In  many  cases  of  hypersecretion  disturbances  of  the  motor  functions 
of  the  stomach  are  present  in  addition. 

GASTROSUCCORRHEA  (CONTINUA  PERIODICA) 

{Synonyms. — Intermittent  Secretion  of   Gastric  Juice;   Intermittent   Hypersecretion; 
Gastroxynsis;  Periodic  Continuous  Flow  of  Gastric  Juice) 

This  type  of  hypersecretion  is  characterized  by  an  acute  attack  of 
continuous  secretion  of  gastric  juice  associated  with  severe  pains  in  the 
stomach,  usually  spasmodic  in  character,  and  by  vomiting  of  acid  fluid, 
the  attacks  generally  occurring  in  the  night  or  early  morning  and  at  irregu- 
lar intervals;  hence  it  is  known  as  intermittent  or  periodic.  Probably 
this  condition  is  more  frequent  among  nervous  cases  than  we  generally 
suppose.  I  have  been  able  to  absolutely  determine  in  several  cases  of 
supposed  intermittent  attacks  of  acute  gastritis,  or  so-called  acute  bilious 
attacks,  that  this  condition  of  intermittent  hypersecretion  was  present. 

History. — Reichmann"^  was  the  first  to  describe  this  perversion  of 
function,  and  Rossbach,^  under  the  nomenclature  gastroxynsis,  described 
what  is  generally  considered  the  same  disease.  Sahli,  Riegel,  and  many 
others  have  written  on  it. 

Etiology. — In  some  cases  it  is  a  neurosis,  or  the  result  of  mental  over- 
excitement  or  of  overexertion;  irritation  of  the  gastric  mucous  membrane, 
as  from  cold  water,  or  smoking  spices,  etc.,  may  precipitate  an  attack. 

It  is  associated  with  the  gastric  crises  of  locomotor  ataxia  in  some 
patients,  or  with  organic  affections  of  the  peripheral  or  central  nervous 
system,  with  gastric  or  duodenal  ulcer,  or  with  the  stenotic  form  of  ectasia 
or  with  acute  dilatation  of  the  stomach.  These  are  not  pure  cases,  but 
have  the  additional  symptoms  incident  to  the  disease. 

Symptoms. — These  usually  begin  during  the  night.  The  patient,  who 
is  generally  apparently  perfectly  well,  suddenly  begins  to  feel  discomfort 
in  the  gastric  region,  which  is  rapidly  followed  by  pain  of  severe  type  and 
generally  spasmodic  in  character.  There  are  nausea,  a  feeling  of  faint- 
ness,  and  the  patient  is  obliged  to  assume  the  recumbent  position.  He 
grows  pale,  the  extremities  become  cold,  and  the  abdomen  at  times  is 
sunken  and  the  pulse  rapid  and  feeble.     The  nausea  becomes  worse  and 

*  Berl.  klin.  Wochenschr.,  1882,  No.  40, 

*  Deutsch.  Arch.  f.  klin.  Med.,  1883,  Bd.  35. 


388  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

worse  and  soon  a  violent  attack  of  vomiting  of  a  large  amount  of  acid  fluid 
takes  place. 

There  is  temporary  relief,  but  the  symptoms  begin  again,  and  after  a 
short  period  the  patient  again  vomits  up  a  large  quantity  of  fluid,  far  out 
of  proportion  to  the  amount  previously  ingested. 

During  the  attack  the  appetite  is  lost  and  there  is  extreme  thirst. 
Severe  headache  and  constipation  generally  accompany  these  attacks. 

The  attacks  generally  occur  in  the  middle  of  the  night  or  early  in  the 
morning,  and  awaken  the  patient  by  the  pain,  if  he  be  sleeping. 

During  the  attack  the  stomach  is  tender  on  pressure  and  there  is  a 
good  deal  of  heart-burn  and  acid  belching,  the  urine  is  scanty,  alkaline, 
and  of  high  specific  gravity. 

Character  of  the  Vomitus. — The  fluid  is  watery  and  very  acid.  It  may 
be  clear  or  somewhat  tinged  with  bile  (yellowish  green). 

There  may  be  particles  of  food  in  the  first  vomit,  if  motor  insufficiency 
is  associated  with  the  condition,  but  in  many  cases  there  is  simply  the 
clear  gastric  juice  alone  or  mixed  with  bile.  If  this  fluid  be  examined  it 
will  be  found  to  contain  free  hydrochloric  acid  in  considerable  quantity, 
rennet,  and  pepsin.  The  desire  to  vomit  frequently  persists,  and  generally 
several  attacks  of  vomiting  succeed  each  other.  Even  though  the  patient 
abstain  from  all  fluid,  in  a  few  hours  or  less  he  will  again  vomit  a  large 
quantity  of  gastric  juice.  Rarely  the  vomitus  may  contain  traces  of 
blood,  which  does  not  necessarily  mean  an  ulcer.  This  condition  may 
last  for  several  hours  or  for  several  days,  when  gradually  the  vomiting 
stops,  the  nausea  and  pain  subside,  and  the  patient  begins  to  desire  food. 
Gradually  the  appetite  returns,  the  food  is  retained,  in  a  few  days  he 
begins  to  feel  nearly  well,  and  in  a  brief  time  is  apparently  in  perfect 
health. 

The  patient  may  continue  in  good  health  for  weeks,  months,  or  a  year, 
and  then  have  a  recurrence.  The  intermissions  of  good  health,  on  the 
other  hand,  may  become  shorter  until,  finally,  the  intermittent  gastro- 
succorrhea  becomes  chronic. 

In  many  cases  during  the  intermissions,  if  the  gastric  contents  are 
analyzed,  they  will  be  found  to  be  perfectly  normal.  On  the  other  hand, 
some  cases  may  suffer  from  mild  symptoms  of  hyperchlorhydria,  and  such 
a  condition  will  be  found  to  exist  on  examination. 

Diagnosis. — This  can  be  made  by  the  characteristic  symptoms  begin- 
ning during  the  night,  the  vomiting  of  pure  gastric  juice  occurring  when 
no  ingesta  are  present  in  the  stomach.  Analysis  shows  that  it  possesses 
all  the  properties  of  the  gastric  juice  with  an  excess  of  free  hydrochloric 
acid.  If  no  food  is  given  and  the  stomach  be  aspirated  before  the  second 
attack  of  vomiting  occurs,  at  the  time  of  appearance  of  pain  and  nausea, 
or  if  the  second  vomitus  be  analyzed,  and  in  either  event  be  found  to  con- 
sist of  a  considerable  quantity  of  pure  gastric  juice,  the  diagnosis  is 
conclusive. 

The  attacks  are  intermittent. 

All  cases  should  be  examined  as  to  motor  functions  and  dilatation, 
since  attacks  of  gastrosuccorrhea  occur  with  these  conditions.  One  should 
also  exclude  organic  disease,  such  as  ulcer  and  the  gastric  crisis  of  loco- 


FUNCTIONAL   DISEASES    OF    THE    STOMACH  389 

motor  ataxia.  In  the  latter  case  we  have  loss  of  patellar  reflexes,  the 
Argyll-Robertson  pupil,  and  the  Rhomberg  symptom  and  the  Wasser- 
mann  reaction  which  should  be  tested  for  in  suspicious  cases. 

Prognosis. — In  pure  cases  of  gastrosuccorrhea  continua  periodica  the 
prognosis  may  be  fairly  good.  It  is  often  possible  to  lessen  the  severity 
of  the  attacks  or  in  some  cases  even  to  effect  a  cure. 

Treatment. — Prophylaxis. — We  must  first  endeavor  to  find  the  cause 
of  these  attacks,  and  by  correcting  it,  prevent  their  occurrence.  In  the 
interval  between  attacks  the  stomach  contents  should  be  examined  after 
a  test-breakfast  or  meal,  and  we  should  determine  whether  or  not  hyper- 
chlorhydria  exists,  or  gastric  or  duodenal  ulcer. 

The  motor  functions  of  the  stomach  should  also  be  carefully  tested, 
and  any  motor  insufficiency  if  present  should  receive  treatment.  If  there 
be  excesses  in  smoking  or  drinking,  tobacco  and  alcohol  should  be  cut  off. 
If  there  are  errors  in  diet,  they  should  be  corrected.  If  mental  overexer- 
tion or  nervous  excitement  is  a  cause,  such  conditions  should  be  corrected. 
If  the  patient  is  neurasthenic,  he  should  receive  careful  treatment.  Hy- 
gienic method  of  living,  exercise  out  of  doors,  horseback  riding,  golf,  etc., 
are  serviceable. 

Treatment  of  the  Attack. — During  the  early  stage,  when  the  pain  and 
nausea  first  begin,  binding  the  free  acid  with  the  whites  of  several  raw 
eggs  beaten  up  in  water  or  in  milk,  or  the  use  of  i  or  2  ounces  (30.0-60.0) 
of  10  per  cent,  gelatin,  or  neutralizing  the  acid  by  the  administration  of 
an  alkali,  such  as  3^^  to  i  dram  (2,0-4.0)  sodium  bicarbonate  in  water, 
4  ounces  (125.0),  or  Vichy;  or  milk  of  magnesia,  H  ounce  (16.0),  or  mag- 
nesia usta,  y^  to  I  dram  (2.0-4.0),  will  at  times  mitigate  the  symptoms. 
Einhorn  recommends  a  large  dose  of  bromid  at  the  appearance  of  the  first 
symptoms,  and  claims  that  it  will  often  cut  the  attack  short  or  lessen  its 
severity.  About  15  to  30  grains  (1.0-2.0)  of  sodium  bromid  should  be 
given,  preferably  in  Vichy  (an  alkali). 

The  patient  should  be  kept  recumbent,  with  the  application  of  moist 
heat  or  dry  heat  (wet  hot  flannel  compress  or  hot-water  bag)  applied  to 
the  gastric  region.     He  will  generally  vomit  in  spite  of  treatment. 

The  best  method,  I  believe,  is  to  perform  lavage  early,  not  waiting 
until  vomiting  occurs,  if  the  pain  and  nausea  are  not  relieved  by  adminis- 
tration of  the  albuminous  food  or  alkalis. 

Wash  the  stomach  thoroughly  with  an  alkaline  solution — i  to  2  quarts 
(liters)  of  warm  water  in  which  2  to  3  ounces  (30.0-45.0)  of  milk  of  mag- 
nesia (Phillips)  have  been  dissolved — or  y<2  ounce  (16.0)  of  sodium  bicar- 
bonate or  yi  ounce  (16.0)  of  magnesia  usta.  Before  withdrawing  the 
tube  after  lavage,  pour  through  it  into  the  stomach  2  drams  (8.0)  of  milk 
of  magnesia  dissolved  in  2  ounces  (30.0)  of  water,  to  which  is  added  10 
drops  (0.6)  tincture  of  belladonna  or  Hoo-J^^o  of  atropine  to  check  further 
secretion.  Sodium  bicarbonate,  i  dram  (4.0),  may  be  substituted  for  the 
magnesia. 

If  the  pain  is  very  severe  it  may  be  necessary  to  give  one  or  several 
h5T5odermics  of  morphin,  \i  to  }i  grain  (0.008-0.016),  preferably  com- 
bined with  atropin,  Xoo  grain  (0.00065),  which  last  is  of  value  to  lessen 
hypersecretion.     Codein  may  be  employed. 


390 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


To  the  use  of  cocain  for  nausea  and  vomiting  I  am  opposed.  It  gives 
but  temporary  relief,  is  a  marked  cardiac  depressant,  many  patients  have 
an  idiosyncrasy  to  even  a  small  amount,  and  there  is  danger  of  the  cocain 
habit. 

It  may  be  necessary  to  repeat  lavage  several  times.  The  belladonna 
or  atropin  should  be  pushed  to  physiologic  limits,  with  dilatation  of  the 
pupils  and  dryness  of  the  throat,  if  one  expects  to  have  any  effect  in  check- 
ing the  hypersecretion. 

Some  recommend  washing  the  stomach  with  i :  2000  silver  nitrate 
solution,  and  following  it  with  plain  warm  water;  argyrol  or  protargol 
(1-2000)  can  be  substituted. 

Some  patients  will  not  consent  to  lavage,  and  in  these  cases  we  can 
simply  give  internally  several  large  doses  of  the  alkalis  with  belladonna 
every  two  to  three  hours,  whether  they  vomit  or  not. 

If  there  is  great  thirst,  a  glass  of  hot  water  in  which  sodium  bicarbonate, 
I  dram  (4.0),  has  been  dissolved  is  of  service,  if  taken  in  small  amounts 
(teaspoonful  doses).  It  often  relieves  the  nausea  and  the  alkali  is  of 
value;  or  a  small  piece  of  cracked  ice  or  an  occasional  teaspoonful  of  cool 
water  can  be  also  employed. 

The  raw  white  of  eggs  beaten  up,  placed  in  a  cup  and  packed  around 
with  ice,  or  the  5  to  10  per  cent,  gelatin,  two  teaspoonfuls  given  every 
half-hour  or  so,  both  relieves  thirst  and  binds  the  acid;  or 

Milk Bviij  (250C.C.);  ^  1  Pack  this 

Oxalate  of  cerium gr.  x  (0.6);  1  dissolved  >     .     . 

Sodium  bicarbonate gr.  xv  to  3  ss  (1.0-2.0)  j  therein.    J 

Give  I  teaspoonful  (4.0)  every  half  hour,  or  so  as  to  relieve  thirst  and 
bind  the  acid,  and  check  nausea  and  vomiting. 

In  some  cases  rectal  enemata  of  hot  normal  salt  solution  at  ii5°F., 
I  pint  (500  c.c),  relieve  thirst  and  stimulate  the  pulse.  It  may  be  neces- 
sary to  employ  smaller  quantities  of  saline  solution  or  to  use  proctoclysis. 

It  is  best  for  the  patient  not  to  drink  too  much  the  first  day  of  the 
attack,  except  the  remedies  noted,  as  an  excessive  amount  of  fluid  favors 
vomiting.  No  food  should  be  given  except  as  above  advised.  On  the 
next  day  small  quantities  of  milk  diluted  with  lime-water  or  matzoon  and 
Vichy  or  albumin- water  can  be  given,  H  to  i  ounce  (16.0-32.0),  every 
hour,  and  the  gelatin  can  be  kept  up. 

The  quantity  of  nourishment  may  then  gradually  be  increased,  and, 
finally,  soft-boiled  eggs,  scraped  raw  meat,  and  a  subsequent  diet  such 
as  is  used  in  hyperchlorhydria. 

The  bowels  should  be  moved  early  in  the  attack  by  a  soapsuds  enema, 
I  quart  (liter),  to  which  8  ounces  (250  c.c.)  olive  oil  have  been  added,  or 
by  enteroclysis. 

To  recapitulate.  In  the  treatment  of  the  acute  attack  I  follow  out  the 
following  method:  Heat  to  the  abdomen,  the  administration  at  once  of 
an  alkali  by  mouth;  the  bowels  are  moved  by  enema,  and  the  stomach, 
after  a  brief  period  of  rest,  washed  with  an  alkali,  preferably  with  milk 
of  magnesia;  2  drams  (8.0)  of  milk  of  magnesia  diluted  with  water,  2  ounces 
(125  c.c),  with  tincture  of  belladonna,  10  drops  (0.6)  or  atropin  (Hoo~ 
}io),  being  poured  into  the  stomach  through  the  tube  before  removal. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH  391 

A  hypodermic  of  morphin  is  then  given,  the  room  darkened,  and  the 
patient  kept  perfectly  quiet.  This  treatment  is  repeated  if  necessary.  If 
the  patient  will  not  consent  to  lavage,  then  alkalis,  gelatin,  and  whites  of 
raw  eggs  with  belladonna  or  atropin  should  be  administered. 

GASTROSUCCORRHEA  (CONTINUA  CHRONICA) 

(Synonyms. — Chronic  Gastrosuccorrhea;  Chronic  Hypersecretion;  Chronic  Parasecre- 
tion;  Chronic  Continuous  Secretion  of  Gastric  Juice;  Reichmann's  Disease) 

Chronic  continuous  secretion  of  the  gastric  juice  is  a  perversion  of 
function  which  is  characterized  by  the  secretion  of  an  excessive  quantity 
of  gastric  juice,  not  only  after  the  ingestion  of  food,  but  also  when  the 
stomach  is  empty. 

The  chief  diagnostic  point  is  the  secretion  of  large  quantities  of  gastric 
juice  in  the  fasting  stomach.  Reichmann,^  in  1882,  was  the  first  to  de- 
scribe this  condition. 

We  must  make  a  distinction  between  the  pure  cases  of  chronic  gastro- 
succorrhea and  those  in  which  dilatation  (atonic)  of  the  stomach  or  dila- 
tation from  stenosis,  especially  with  ulcer,  exist,  and  with  which  h5^er- 
secretion  is  an  associated  symptom. 

After  fasting,  small  quantities  of  gastric  juice,  as  much  as  5  to  10  c.c. 
or  15  to  30  c.c,  on  one  or  two  occasions  have  been  aspirated.  Thus  the 
possibility  of  a  normal  small  secretion  may  exist.  If,  however,  we  find 
20  to  30  c.c.  or  more  of  gastric  juice  constantly  in  the  stomach  of  a  patient 
who  has  been  fasting  for  some  time  with  the  clinical  symptoms  described, 
the  finding  we  would  consider  to  be  pathologic  and  to  be  an  evidence  of 
continuous  hypersecretion. 

Rehfuss  has  reported  a  number  of  cases  of  aspiration  of  the  fasting 
stomach  with  75  to  100  c.c.  gastric  juice  and  yet  no  hypersecretion.  He 
therefore  states  that  more  than  this  quantity  should  constitute  hyper- 
secretion and  believes  former  methods  of  aspiration,  as  compared  with 
his  fractional  method,  are  faulty.  These  subjects  of  Rehfuss  gave  no 
symptoms.  The  fractional  method  (long  continued  presence  of  the  tube) 
may  in  itself  excite  more  secretion.  Moreover  we  see  patients  with  a 
free  HCl  (hyperchlorhydria)  giving  no  symptoms.  If  the  fasting  juice 
be  over  20-30  c.c.  plus  the  symptoms,  hypersecretion  may  be  fairly 
diagnosed. 

Frequency. — Cases  of  pure  gastrosuccorrhea  chronica  without  any 
associated  organic  lesions  of  the  stomach  I  believe,  with  Einhorn,  to  be 
quite  a  rare  disease,  while  those  found  in  association  with  ectasia  are  not 
uncommon.  Undoubtedly  the  latter  class  have  been  confused  with  the 
pure  cases.     Chronic  hypersecretion  is  more  rare  than  the  periodic  type. 

Etiology. — Chronic  hypersecretion  occurs  more  frequently  in  men  than 
women,  and  in  youth  and  middle  life. 

Severe  mental  strain  or  worry  seem  to  be  factors,  also  the  neurotic 
condition,  and  vagotonia. 

The  periodic  type  may  develop  into  the  chronic;  persistent  hyper- 
chlorhydria or  its  causes,  such  as  indigestible  or  irritating  food  or  condi- 

^  Berlin,  klin.  Wochenschr.,  1882,  No.  40. 


392  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

merits,  the  abuse  of  alcohol  or  tobacco,  or  excessive  hot  or  cold  food  and 
drinks,  may  be  factors. 

Dilatation  of  the  stomach,  ulcer  of  the  stomach  or  duodenum,  or 
tetany  may  have  chronic  gastrosuccorrhea  associated  with  them. 

One  must  also  remember  that  chronic  hypersecretion  may  be  reflexly 
produced  by  disease  of  some  other  organ,  the  appendix,  gall-bladder,  pan- 
creas, tuberculosis,  or  a  new  growth  of  the  cecum,  and  that  severe  inflam- 
mation of  the  stomach,  Fenwick^  believes,  may  follow,  and  that  even  gas- 
tric ulcer  or  ulcer  of  the  duodenum  may  on  the  other  hand  result.  This 
same  hypersecretion  may  give  rise  to  spasm  of  the  pylorus,  causing  pain 
and  intermittent  obstruction.  Fenwick  even  goes  so  far  as  to  state  that 
the  character  of  the  inflammation  of  the  appendix  is  indicated  by  the  gas- 
tric secretion;  an  active  irritation  being  indicated  by  hypersecretion,  while 
torsion,  thickening,  cystic  dilatation  or  adhesion  are  followed  after  a  time 
by  a  type  of  chronic  gastritis  characterized  by  flatulence,  nausea,  anorexia, 
excess  of  mucus,  and  absence  of  free  hydrochloric  acid.  This  last  corre- 
sponds nearly  to  the  achlorhydria  gastrica  haemorrhagica  described  by 
Pilcher^  in  Mayo's  clinic. 

Sjrmptoms. — In  most  of  the  cases  the  patients  state  that  the  gastric 
symptoms  began  gradually,  a  feeling  of  pressure,  fulness,  and  sour  eructa- 
tion commencing  a  couple  of  hours  after  the  ingestion  of  food,  resembling 
the  symptoms  of  hyperchlorhydria.  Then  pain  occurs  several  hours  after 
meals  or  shortly  before  the  ensuing  meal;  it  is  most  frequent  on  the  empty 
stomach,  just  before  the  next  meal  is  due.  It  may  be  spasmodic  in  char- 
acter; nausea  and  then  vomiting  follows.  The  vomiting  may  increase  in 
frequency,  and,  finally,  occur  several  times  a  day  after  breakfast  and  sup- 
per. In  some  cases  the  attacks  take  place  during  the  night  between  12 
and  2  o'clock,  the  patient  being  awakened  by  burning  and  pain  in  the  epi- 
gastrium, acid  eructations,  and,  finally,  vomiting  of  very  acid  fluid  takes 
place;  after  vomiting  the  pain  is  relieved.  The  night  vomitus  is  generally 
a  clear  fluid.  Albuminous  food,  egg  or  milk,  will  often  relieve  the  pain. 
The  day  vomitus  is  very  acid  (quite  liquid),  but  some  food  is  mixed  with 
it;  is  often  of  a  grass-green  color. 

The  appetite  is  generally  good  and  often  increased.  Sometimes  the 
patient  develops  excessive  hunger;  loss  of  appetite  is  rather  rare. 

Thirst  is  increased,  the  bowels  are  constipated,  the  urine  diminished 
and  less  acid  than  normal. 

There  may  be  some  loss  of  weight,  but  ho  marked  emaciation. 

The  contrast  between  the  physical  condition  of  the  pure  type  of  chronic 
hypersecretion  and  that  in  which  dilatation  of  the  stomach  accompanies 
it  will  be  described  under  Diflferential  Diagnosis. 

Palpation. — The  stomach  is  more  or  less  sensitive  to  pressure. 

Diagnosis. — The  diagnosis  of  gastrosuccorrhea  continua  chronica  can 
only  be  made  by  examination  of  the  stomach  in  the  fasting  condition.  To 
exclude  error,  the  method  suggested  by  Reichmann  is  the  best. 

^  The  Clinical  Significance  of  Gastric  Hypersecretion  and  Its  Connection  with 
Latent  Disease  of  the  Appendix,  Proc.  Royal  Soc.  Med.,  April,  1910,  Surg.  Sect.,  p. 
177. 

*  Jour.  Amer.  Med.  Assoc.,  Nov.  19,  1910,  p.  1790. 


FUNCTIONAL   DISEASES    OF   THE    STOMACH  393 

The  stomach  should  be  thoroughly  washed  out  with  warm  water, 
preferably  at  night,  all  food  and  drink  should  be  withheld  for  ten  to  twelve 
hours,  and  then  aspiration  of  the  stomach  contents  should  he  performed. 
Anywhere  from  50  to  125  c.c.  of  gastric  contents  are  thus  obtained.  This 
secretion  exhibits  all  the  properties  of  the  gastric  juice.  It  contains  no 
particles  of  food.  The  fluid  is  usually  watery  and  clear  in  color  or  it  may 
be  yellowish  green  from  admixture  with  bile.  There  is  an  increased  degree 
of  acidity,  the  values  for  free  hydrochloric  acid  being,  as  a  rule,  pretty 
high.  There  are  no  starchy  products  contained  therein.  There  are  no 
evidences  of  fermentation  and  no  organic  acids  present.  Under  the  micro- 
scope no  sarcinae  are  found. 

An  hour  after  Ewald's  test-breakfast  more  liquid  than  usual  is  present 
and  the  acidity  is  quite  high  (75  to  125),  higher  than  when  the  fasting 
contents  are  aspirated.  A  thin  disk  of  egg-albumen  will  be  digested  at 
blood  temperature  in  an  hour  or  so.  Lugol's  solution  gives  a  blue  or  violet 
reaction,  showing  the  starch  is  unchanged  or  slightly  so. 

Three  to  four  hours  after  Riegel's  test-dinner  hardly  any  meat  fibers 
are  found,  whereas  considerable  starchy  material  is  present.  The  acid 
content  is  high  and  the  residue  considerable. 

We  must  remember  that  the  above  description  is  a  case  of  pure  chronic 
gastrosuccorrhea  in  which  there  is  no  motor  insufficiency.  These  cases 
I  believe  to  be  quite  rare. 

Differential  Diagnosis. — Many  of  our  writers  do  not  properly  dis- 
tinguish between  cases  of  pure  chronic  hypersecretion  and  those  in  which 
dilatation  of  the  stomach  is  a  complication.  The  examination  of  the  stom- 
ach as  regards  its  size,  position,  and  motor  functions  should  always  be 
carried  out,  and  this  will  aid  us. 

Ulcer  of  the  stomach  may  be  complicated  by  hypersecretion,  and  in  a 
few  rare  cases  gastric  tetany  is  associated  with  it.  Occasionally  no  symp- 
toms pointing  to  a  previous  ulcer  can  be  obtained,  though  there  may  have 
been  a  previous  history  of  hyperchlorhydria,  and  at  subsequent  operation 
the  stenosis  will  be  found  to  be  due  to  an  ulcer  not  entirely  healed. 

In  ectasy  from  pyloric  benign  stenosis  with  hypersecretion  we  have  ex- 
cessive vomiting  of  a  large  quantity  of  greenish-yellow  fluid,  pain,  cramp- 
like attacks,  peristaltic  unrest,  excessive  thirst,  skin  over  the  abdomen 
dry  and  wrinkled,  loss  of  weight  which  is  often  very  great,  and  occasion- 
ally some  tinge  of  blood  in  the  vomitus.  The  patient  presents  almost  a 
cachectic  appearance,  and  there  is  in  some  patients  the  sense  of  resistance, 
or  even  a  feeling  of  thickening  at  the  pylorus. 

The  vomitus  or  contents  aspirated  after  a  test-meal  will  separate  into 
three  layers:  an  upper  layer  of  foam,  middle  layer  yellow  or  yellowish 
green,  and  a  lower  layer  of  sediment.  Meat  is  digested,  the  sediment 
consists  of  starchy  material.  Acidity  is  markedly  increased  and  content 
of  hydrochloric  acid  is  high.  Pepsin  digestion  is  rapid.  Starchy  materials 
yeast-cells,  and  sarcinae  are  found  under  the  microscope. 

Examination  further  shows  marked  dilatation  of  the  stomach,  with 
great  relative  motor  insufficiency.  Hyperchlorhydria  with  atonic  dilatation 
must  also  he  differentiated.  The  pain  and  vomiting  occurring  in  some  cases 
present  some  of  the  symptoms  of  hypersecretion. 


394  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

For  example,  in  one  case  a  test-meal  given  at  night  shows  A.  M.  on 
aspiration  500  c.c.  of  contents;  separating  into  three  layers,  fermentation 
being  present,  stomach  one  finger  below  umbilicus.  Reichmann's  method 
was  then  employed,  i.e.,  the  stomach  was  thoroughly  washed  out  and  noth- 
ing given  for  twelve  hours.  Morning  aspiration  showed  the  organ  to  be 
empty,  no  secretion,  hence  the  diagnosis  was  clear. 

In  many  cases  of  marked  stagnation  of  the  stomach-contents  with 
dilatation,  continuous  secretion  may  be  simulated.  The  method  of  test- 
ing the  empty  stomach  will  determine  the  diagnosis. 

If  there  have  been  hematemesis,  melena,  circumscribed  tenderness,  or 
dorsal  tenderness,  ulcer  will  be  suspected.  Frequent  examinations  for 
occult  blood  in  the  stomach  contents  and  stool  are  of  service.  The  x- 
rays  should  be  employed  for  diagnosis  when  stenosis  or  ulcer  are 
suspected. 

Tetany  may  complicate  hypersecretion  with  dilatation.  The  symp- 
toms are  characteristic. 

Prognosis. — In  the  cases  of  pure  chronic  hypersecretion  the  prognosis 
is  fairly  good.  Most  patients  improve  under  treatment,  but  quite  fre- 
quently there  are  relapses.  Sometimes  the  condition  persists  for  years. 
Hypersecretion  per  se  is  never  fatal.  When  complications  such  as  dila- 
tation of  the  stomach  are  present,  the  serious  features  are  dependent  on 
them. 

Treatment. — Prophylaxis. — The  patient  should  not  overwork,  should 
be  relieved  of  all  mental  overexertion,  and  lead  a  rational  out-of-door  life, 
with  proper  attention  to  exercise  and  hygiene.  Nervous  conditions  when 
present  should  be  treated.  The  patient  should  avoid  bolting  his  food, 
should  not  eat  any  irritating  substances,  such  as  mustard,  pepper,  spices, 
alcohol,  and  very  hot  and  very  cold  food  and  drink;  in  fact,  he  should 
avoid  everything  that  will  overstimulate  the  secretion  of  gastric  juice. 
Avoid  smoking. 

Albuminous  food  is  digested  well,  and  starchy  food,  badly;  hence  the 
latter  should  be  reduced  in  quantity. 

Diet. — This  is  practically  the  same  as  in  hyperchlorhydria,  except  that 
very  large  quantities  of  fluid  should  be  avoided. 

If  the  appetite  and  physical  condition  are  good,  it  is  just  as  well  to  give 
but  three  meals  a  day,  so  as  to  give  the  stomach  a  rest  and  not  tend  to 
keep  up  gastric  secretion.  In  this  event  the  excessive  acidity  can  be  neu- 
tralized between  feedings  by  alkalis.  Doses,  }-i  to  i  dram  (2.0-4.0)  of 
magnesia  usta,  milk  of  magnesia,  or  soda  bicarbonate  should  be  given,  as 
in  hyperchlorhydria,  in  water  one  to  two  hours  after  meals,  and  the  hyper- 
secretion and  the  pain  relieved  by  tincture  of  belladonna,  10  drops  (0.6), 
or  atropin,  gr.  Hoo-Ho  t.i.d. 

On  the  other  hand,  some  patients,  as  in  hyperchlorhydria,  readily  feel 
satiated,  and  yet  desire  food  frequently.  They  may  also  be  losing  some 
weight,  especially  in  the  cases  complicated  with  dilatation;  small  meals, 
which  are  readily  expelled  from  the  stomach  (i.e.,  in  soluble  form  or 
mushes),  must  be  given,  and  yet  the  nutrition  must  be  kept  up,  which  last 
necessitates  frequent  feeding. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH  395 

The  diet,  for  example,  when  given  in  small  frequent  meals  would  be 
as  in  hyperchlorhydria,  but  less  fluid: 

7.30  A.  M. — Milk  or  cocoa,  250  c.c.  (8  ounces),  2  zwieback  or  toast  and  egg  (i). 
10.00  A.  M. — Beef  sandwich  or  ham  sandwich. 
1.30  P.  M. — Soup,  250  c.c.  (8  ounces),  with  raw  egg,  steak  (100  grams),  potatoes 

(50  grams). 
4.00  p.  M. — Same  as  10  a.  m. 
7.00  p.  M. — 2  eggs  or  meat  (100  grains),  2  slices  toast,  butter  (20  grams). 

If  there  is  dilatation,  more  soluble  food  should  be  given  (see  Dilatation 
of  the  Stomach).  Starches  should  be  given  thoroughly  cooked,  or  pre- 
digested  and  in  small  amounts,  and  preferably  in  soups  and  mushes; 
potatoes  should  be  mashed  and  alcohol  avoided;  also  avoid  cabbage, 
turnips,  spices,  pickles,  mustard,  etc. 

Medicaments. — To  lessen  hypersecretion. 

Tincture  belladonna  in  doses  of  10  drops  (0.6)  or  more,  t.i.d.  before 
meals,  up  to  physiologic  effects,  or  extract  belladonna,  3^  to  ^  grain 
(0.01-0.02),  will  lessen  secretion  and  subsequent  h)q5ersecretion.  Atropin, 
Hoo  to  }4o  grain  (0.0006-0.0014)  t.i.d.,  by  mouth  or  hypodermic,  is  also 
of  value;  the  pain  and  the  spasm  of  the  pylorus  and  the  hypersecretion 
are  lessened  by  these  remedies. 

One  can  administer  a  large  dose  of  belladonna  after  lavage  before 
withdrawing  the  tube.  Bismuth  subnitrate,  30  grains  (2.0),  in  2  ounces 
(60.0)  water,  t.i.d.  half  an  hour  before  meals,  or  olive  oil,  i  ounce  (30.0) 
t.i.d.  before  meals,  or  the  latter  containing  30  grains  (2.0)  of  bismuth, 
lessen  secretion. 

Large  doses  of  morphin,  as  have  been  recommended,  I  believe  to  be  a 
pernicious  method  for  obvious  reasons. 

For  Attacks  of  Pain. — Alkalis,  such  as  milk  of  magnesia  (PhiUps), 
H  ounce  (15.0)  in  2  ounces  (60.0)  of  water,  or  magnesia  usta,  i  dram 
(4.0),  or  soda  bicarbonate  alone,  i  dram  (4.0),  or  combined  with  the  above, 
are  of  service.  Albumin-water  (white  of  raw  egg)  or  gelatin,  5  to  10  per 
cent,  solution,  i  ounce  (30.0),  are  useful.  Heat  should  be  applied  ex- 
ternally. Lavage,  preferably  with  an  alkaline  solution,  with  i  ounce  (30.0) 
milk  of  magnesia  in  i  quart  (liter)  of  warm  water,  or  with  soda  bicarbonate, 
}^  ounce  (15.0),  or  magnesia  usta,  }-i  ounce  (15.0)  in  the  same  amount  of 
water,  is  the  best  method.  A  small  quantity  may  be  left  in  the  stomach 
and  belladonna,  10  drops  (0.6),  or  atropin,  gr.  }4o}  with  an  additional  dose 
of  the  alkali  poured  in  before  removing  the  tube. 

In  some  cases  it  may  be  necessary  to  administer  a  hypodermic  of  codein, 
H  to  j-i  grain  (0.0016-0.032),  or  morphin,  }^  to  K  grain  (0.008-0.016). 
They  should  only  be  given  by  a  nurse  or  physician. 

Alkalis. — If  there  be  no  ectasy,  a  course  at  Carlsbad  is  of  service,  or 
artificial  Carlsbad  salts  or  the  imported  salts,  or  alkaline  mineral  waters, 
such  as  Vichy,  can  be  taken  at  meals  or  just  before  meals.  This  lessens 
hyperacidity  and  thus  aids  digestion. 

To  prevent  subsequent  attacks  of  pain  an  alkali  should  be  given  at 
the  height  of  digestion,  about  two  to  two  and  a  half  hours  after  food; 
magnesia  usta  or  milk  of  magnesia,  >^  to  2  drams  (2.0-8.0),  alone  or  com- 


396  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

bined  with  soda  bicarbonate  oc  ammonia  magnesia  phosphate,  as  described 
under  Hyperchlorhydria,  are  useful. 

Lavage. — Reichmann  and  Riegel  were  the  first  to  recommend  lavage 
for  the  treatment  of  this  condition.  Reichmann  and  Einhorn  perform 
lavage  in  the  morning  with  the  stomach  fasting,  while  Riegel  washes  it 
out  six  or  seven  hours  after  the  heavy  meal.  My  method  is  entirely  de- 
pendent on  the  time  of  appearance  of  the  symptoms.  If  the  attack  comes 
on  at  midnight  or  early  in  the  morning,  it  seems  most  logical  to  perform 
thorough  lavage  at  bedtime  with  an  alkaline  solution,  leaving  some  of  it 
in  the  organ,  and  also  pouring  into  it  a  large  dose  of  belladonna,  10  to  15 
drops  (0.6-1.0)  or  >^o  atropin. 

If  the  attacks  come  on  after  breakfast  or  the  noon  meal,  then  the 
early  morning  lavage  on  the"  empty  stomach  seems  best.  I  often  recom- 
mend pouring  Carlsbad  salts  directly  through  the  tube  before  withdrawal. 
With  severe  pain  it  may  be  necessary  to  perform  lavage  again  during  the 
exacerbation. 

If  there  be  dilatation  and  marked  retention  of  food,  lavage  six  hours 
after  the  full  noon  meal  is  necessary,  then  followed  by  a  light  supper;  an 
alkali  and  belladonna  or  atropin  should  be  given  at  bedtime. 

In  some  obstinate  cases  Reichmann  recommends  lavage  with  i :  1000 
to  1 :  2000  silver  nitrate  solution.  It  is  safest  to  wash  the  stomach  with 
about  500  c.c.  of  this  solution,  150  c.c.  at  a  time,  and  then  wash  out  the 
stomach  with  warm  water.  Argyrol  or  protargol  1-2000  may  be  employed. 
Normal  salt  solution  may  be  substituted  if  there  is  much  irritation.  Some 
also  recommend  the  internal  administration  of  3^^  to  3*^  grain  (0.011-0.016) 
of  silver  nitrate  in  pure  form  or  in  solution  t.i.d.  and  at  bedtime. 

Stomach  Spray. — Einhorn  claims  excellent  results  from  spraying  the 
stomach  with  his  gastric  spray  with  nitrate  of  silver  i  :  2000  to  i  :  1000 
after  a  previous  washing  with  warm  water. 

Direct  Galvanization. — The  same  author  reports  good  results  from  in- 
ternal galvanization  of  the  stomach,  employing  it  and  the  gastric  spray  on 
alternate  days.  Riegel  finds  no  benefit  from  intragastric  galvanization 
unless  atony  is  present,  and  in  this  I  agree. 

If  the  condition  of  chronic  hypersecretion  be  complicated  by  dilatation, 
this  condition  must  be  treated.  Rose's  belt  is  of  value  for  atonic  ectasia. 
If  there  is  pyloric  stenosis,  gastro-enterostomy  is  indicated. 

Lavage  with  an  alkali,  belladonna  or  atropin  in  large  doses,  the  alka- 
line treatment,  diet,  and  in  some  cases  spraying  or  lavage  with  nitrate  of 
silver,  i  :4ooo  or  argyrol  or  protargol  i  :25oo  several  times  a  week,  are 
the  chief  requirements. 

ALIMENTARY  HYPERSECRETION 

This  rare  condition,  believed  by  some  to  be  a  neurosis,  is  characterized 
by  an  excessive  quantity  of  gastric  juice  secreted  within  the  stomach  dur- 
ing digestion.  This  hypersecretion  ceases  when  the  contents  have  escaped 
from  the  organ,  so  that  the  fasting  stomach  is  empty.  This  is  unlike  the 
other  types  of  hypersecretion  in  which  gastric  secretion  is  secured  from 
the  stomach  when  empty  of  food. 


FUNCTIONAL   DISEASES   OF   THE   STOMACH  397 

Etiology. — Claims  are  made  that  alimentary  hypersecretion  occurs  with 
atony  and  gastroptosis.  The  media  between  the  residuum  found  in 
these  cases  is  due  to  disturbance  of  motility.  There  are  various  theories 
advanced  for  this  condition,  a  primary  neurosis  or  irritant  from  undigested 
starch,  but  I  am  inclined  to  believe  that  these  cases  are  complicated  by 
some  small  gastric  erosion,  undetectable  by  the  ac-rays,  which  act  as  an 
irritant  only  at  the  time  of  food  ingestion. 

On  aspiration  of  the  test  meal  one  finds  the  liquid  contents  three  or 
four  times  in  excess  over  the  solid — and  with  the  Boas  dry  meal — an  excess 
of  liquid.    The  gastric  findings  are  frequently  hyperacid  but  not  always  so. 

Sjmiptoms. — In  the  writer's  experience  these  patients  have  many  symp- 
toms like  gastric  ulcer,  particularly  pain  and  heart-burn,  and  are  troubled 
with  constipation.  They  are  often  nervous  or  neurotic.  I  have  not  ob- 
served the  great  loss  of  weight  as  noted  by  Boas  and  others. 

The  writer  has  held  these  cases  to  be  practically  small  erosions  with 
disturbances  of  secretion  which  may  if  untreated  result  in  gastric  ulcer. 

Treatment. — The  diet  depends  on  whether  hyperacidity  or  hypoacidity 
is  present  and  is  followed  out  on  these  lines:  The  treatment  is  the  medical 
treatment  of  gastric  ulcer — atropin  or  belladonna  are  of  value  to  lessen 
secretion  and  the  alkalis  are  of  service.  Even  if  acidity  is  not  marked, 
it  is  sufficient  to  cause  irritation.  Lavage  several  times  a  week  with  silver 
nitrate  1 14000  or  protargol  or  argyrol  i :  2500  is  of  value. 


CHAPTER  XV 

DISTURBANCES  OF  THE  MOTOR  FUNCTION  OF  THE  STOMACH 
—ACUTE  ATONY— CHRONIC  ATONY— ACUTE  DILATATION 
OF  THE  STOMACH— CHRONIC  DILATATION  OF  THE 
STOMACH 

ATONY  OF  THE  STOMACH— DIMINISHED  PERISTOLE 

Atony  of  the  stomach  (or  diminished  peristole)  may  be  defined  as  a 
relaxation  and  weakening  of  the  muscular  wall  of  the  organ,  so  that  it 
cannot  empty  itself  in  the  normal  time,  and  thus  motor  insufficiency 
results.  It  is  a  perversion  of  motor  function.  With  simple  atony,  the 
stomach  is  of  normal  size,  but  motor  insufficiency  exists.  When  the  organ 
is  enlarged,  we  speak  of  ectasy  or  dilatation,  which  is  combined  with 
motor  insufficiency. 

There  are  two  types  of  atony  of  the  stomach :  First,  acute  atony;  second, 
chronic  atony. 

Acute  Atony  of  the  Stomach — Acute  Diminished  Peristole 

Acute  atony  of  the  stomach  may  occur  as  a  preliminary  to  acute 
dilatation  of  the  stomach,  just  as  may  chronic  atony  to  chronic  atonic 
dilatation. 

Acute  atony  does  not  necessarily  result  in  acute  dilatation. 

Many  of  the  causes  which  produce  acute  dilatation  are  the  factors 
with  acute  atony,  but  the  stomach  has  not  become  dilated.  The  early 
recognition  of  the  condition  is,  therefore,  important.  The  motor  insuffi- 
ciency which  occurs  with  it  may  also  lead  to  error  in  diagnosis.  The  con- 
dition takes  place  most  frequently  after  overloading  the  stomach,  bolting 
the  food,  or  indigestible  food,  or  alcohol.  It  may  complicate  acute  gas- 
tritis, with  belching,  fulness  or  discomfort  in  the  stomach,  some  distention, 
constipation,  and  delayed  vomiting;  in  fact,  merely  discomfort  for  a  con- 
siderable period  of  time  and  then  the  vomiting  of  food  taken  some  hours 
before.  The  splashing  sound  is  present.  The  stomach  becomes  distended, 
tympanitic,  and  often  sensitive  to  pressure.  A  sudden  attack  of  retention 
of  chyme  for  an  abnormal  length  of  time  is  the  salient  symptom. 

In  one  case,  because  of  motor  insufficiency  following  a  single  dietary 
indiscretion,  a  diagnosis  of  ectasy  with  motor  insufficiency  was  made. 
Examination  demonstrated  normal  functions,  the  attack  evidently  being 
an  acute  atony  (acute  motor  insufficiency)  of  temporary  duration. 

During  typhoid  or  the  infectious  diseases,  gastric  disturbances  with 
belching,  discomfort,  sudden  distention  of  the  stomach,  constipation,  or 
diarrhea,  with  delayed  vomiting,  the  vomitus  consisting  of  milk  (curdled) 
or  other  food  taken  some  hours  previously,  are  significant  of  this  condition. 

398 


ATONY    OF   THE    STOMACH  399 

There  may  be  evidences  in  the  stool  of  nourishment  taken  forty-eight  hours 
before. 

Treatment. — The  immediate  emptying  of  the  gastro-intestinal  tract  is 
the  indication.     Lavage  should  be  performed  at  once. 

A  good  cathartic,  calomel,  3  to  5  grains  (0.2-0.3),  or  blue  mass,  5  grains 
(0.3),  followed  by  a  saline  cathartic,  should  be  given. 

Castor  oil,  i  to  2  ounces  (30.0-60.0),  is  also  excellent.  Enemata,  and 
especially  rectal  irrigation,  are  of  value  to  produce  intestinal  peristalsis. 

Acute  atony  may  progress  rapidly  to  acute  dilatation  or  develop  more 
slowly  for  ten  to  twelve  hours,  and  then,  if  untreated,  result  in  acute 
ectasy.     Its  early  recognition  is,  therefore,  important. 

CHRONIC  ATONY  OF  THE  STOMACH— CHRONIC  DIMINISHED  PERISTOLE 

(^Synonyms. — Motor  Insufi&ciency;  Gastric  Insufficiency;  Motor  Insufficiency  of  the 
First  Degree;  Myasthenia  Ventriculi;  Atonia  Gastrica^) 

Chronic  atony  of  the  stomach,  if  untreated,  may  result  in  the  atonic 
type  of  dilatation  of  the  stomach. 

Its  correction  is,  therefore,  of  great  importance.  We  use  the  term 
"chronic"  in  distinction  from  the  acute,  evanescent  form.  In  the  pure 
cases  no  dilatation  is  present. 

Etiology. — Atony  of  the  stomach  may  complicate  many  digestive  dis- 
orders, such  as  chronic  gastritis,  hyperchlorhydria,  neurasthenia  gastrica, 
and  diseases  of  the  heart  and  lungs,  as  tuberculosis.  It  occurs  in  nervous 
and  hysteric  subjects  and  may  exist  as  a  primary  neurosis. 

It  may  occur  as  a  result  of  biliary  colic  or  the  crisis  of  tabes. 

Symptoms. — If  atony  occurs  as  a  complication  of  some  other  affection 
of  the  stomach,  its  symptoms  will  be  overshadowed  by  the  primary  dis- 
ease. The  characteristic  symptoms  of  atony  are:  a  feeling  of  fulness  after 
meals,  slight  distention,  belching  of  gas,  diminution  of  appetite,  headache, 
and  constipation.  The  resulting  motor  insufl&ciency  is  productive  of 
fermentation  and  gas  production. 

Physical  Examination. — There  is  generally  some  distention  of  the 
stomach  with  gas.  The  splashing  sound  is  easily  produced  over  the 
greater  part  of  the  stomach  an  hour  or  two  after  the  test-breakfast,  or 
four  or  five  hours  after  a  full  meal.  If  the  splash  extend  to  the  umbilicus 
or  below  it,  this  is  evidence  that  dilatation  is  associated. 

If  movable  kidney  is  associated,  gastroptosis  is  present.  These  are 
not  pure  cases. 

An  hour  after  Ewald's  test-breakfast  aspiration  of  the  stomach  con- 
tents will  remove  100  c.c.  or  more  of  gastric  contents;  an  excellent  test 
taken  in  connection  with  the  symptoms. 

Six  hours  after  Leube's  test-dinner,  aspiration  and  lavage  show  con- 
siderable chyme,  150  to  200  c.c.  The  fasting  stomach  in  the  morning  is 
found  empty. 

Boas  states  that  on  filling  the  stomach  with  water,  the  greater  curva- 
ture will  descend  as  water  is  added.     This  is  not  reliable.     The  lower 

*  Rose  has  called  to  our  attention  that  atonia  gastrica  is  an  improper  term,  really 
meaning  abdominal  relaxation.  It  is  so  applied  in  our  work  "  Atonia  Gastrica  "  to 
define  splanchnoptosis. 


400  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

border  will  descend  after  a  moderate  amount  of  water,  if  the  stomach  is 
dilated. 

Prognosis. — This  is  good  if  proper  treatment  is  instituted. 

Treatment. — If  hyperchlorhydria  or  chronic  gastritis  is  present,  each 
should  receive  appropriate  treatment;  as  should  tuberculosis,  endocarditis, 
nervous  conditions,  etc. 

In  all  cases  of  chronic  atony  of  the  stomach,  Rose's  plaster  belt  is  indi- 
cated. Atony  of  the  intestines  is  frequently  associated,  and  the  use  of 
mechanic  support  lends  tone  to  the  general  musculature  of  the  abdomen, 
keeps  the  stomach  well  supported,  and  prevents  atonic  dilatation  of  the 
organ. 

Vibratory  massage  or  massage  over  the  entire  gastro-intestinal  tract  is 
of  value.  It  stimulates  the  muscles  and  lessens  the  tendency  to  consti- 
pation. Outdoor  exercise,  walking,  golf,  and  horseback  riding  are  indi- 
cated. In  some  cases  douching  the  abdomen  is  of  service;  in  this  event 
one  must  employ  a  silk  elastic  abdominal  support,  or  Lane's  leather  pad, 
which  can  be  readily  removed.  I  have  secured  the  best  results  with 
Rose's  belt.  The  patient  should  not  overwork,  either  mentally  or  physi- 
cally, and  should  eat  slowly  and  masticate  the  food  thoroughly;  the  teeth 
should  be  kept  in  good  condition.  An  excessive  quantity  of  fluid  should 
not  be  taken — in  all,  including  water,  soups,  tea,  etc.,  not  over  i}4  liters 
a  day. 

It  is  best  to  give  numerous  divided  meals  of  rather  moderate  size,  four 
or  even  five  daily,  so  as  not  to  overburden  the  stomach  with  three  large 
meals,  and  allow  it  to  thoroughly  empty  itself.  This  can  be  aided  by 
lying  on  the  right  side  for  15  minutes  or  more  after  each  meal. 

The  diet  may  include  bread  (fresh  and  hot  breads  are  interdicted)  and 
butter,  eggs  in  various  forms,  cereals,  milk,  soup,  chicken,  steak,  chops, 
game,  squab,  fish,  oysters,  and  green  vegetables,  which  are  specially 
valuable  for  the  constipation;  cocoa,  weak  tea,  occasionally  weak  coffee, 
with  milk  and  sugar.  The  diet  must  be  modified  if  hyperchlorhydria  or 
chronic  gastritis  is  present,  or  to  suit  the  special  idiosyncrasies  of  the  pa- 
tient. Alcohol  should  be  interdicted.  An  occasional  cigar  smoked  with 
a  holder  or  two  or  three  pipes  daily  are  allowable  unless  there  is  catarrh 
of  nasopharynx  or  stomach. 

Medicaments. — Strychnin  or  nux  vomica  is  of  great  service  to  tone  up 
the  muscular  system.     They  may  be  given  alone,  or 

IJ.  Tr.  nucis  vomicae iiEx  (0.59  c.c);  1  ^^^  ^^^ 

Comp.  tinct.  cinchona nijxv  (0.888  c.c). — M.  j 

Sig. — Give  in  a  wineglassful  of  water  t.i.d.  half  an  hour  before  meals. 
Some  prefer  it  at  the  same  time  after  meals. 

or,  if  the  patient  is  anemic,  it  may  be  combined  with  iron  and  arsenic,  thus: 

I^.  Strych.  sulph gr.  Ho  (0.0021); 

Sod.  arsen gr.  Ho  (0.0013); 

Blaud's  iron  pill gr.    v  (0.3). — M. 

One  pill;  administer  t.i.d.  after  meals. 

Strychnin  sulphate,  J^o  to  ^0  grain  (0.00108-0.02 1),  is  excellent,  or 


ACUTE   DILATATION   OF    THE    STOMACH  4OI 

tincture  nux  vomicae  in  combination  with  fluidextract  of  condurango,  or 
compound  tincture  of  cinchona,  thus: 

^.  Tinct.  nucis  vomicae,       1  ==  /  u     .     k--\      ■., 

■n.1  -A     ..  A  \ aa     125    c.c.     (about     5ii). — M. 

Fluidext.      condurango  J  "^  ^  " 

Dose,  20  drops  in  water,  t.i.d.  before  meals. 

If  hyperchlorhydria  is  present,  I  omit  strychnin;  though  Musser  advo- 
cates nux  in  the  neurotic  type.  Strychnine  may  be  given  if  belladonna 
is  added. 

Other  iron  preparations  such  as: 

Iron  tropon 3j  to  ij  (4.0-8.0),  t.i.d. 

can  be  given. 

Electricity. — This  is  of  service  applied  by  the  external  method  or,  in 
some  cases,  by  intragastric  faradization. 

Static  electricity  or  the  high-frequency  current  may  be  useful  in  nerv- 
ous cases. 

Lavage  is  not  indicated. 

Massage  or  vibratory  massage  is  especially  useful. 

For  Constipation. — The  green  vegetables,  brown,  rye,  and  Graham 
bread,  and  raw  or  stewed  fruits  are  serviceable.  A  glass  of  water  should 
be  taken  on  rising.  The  patient  should  accustom  himself  to  go  to  stool 
at  a  definite  hour,  and  on  the  closet  may  gently  massage  the  stomach 
and  bowels  to  aid  action. 

A  small  gluten  or  glycerin  suppository,  or  the  injection  of  i  ounce  (30.0) 
of  olive  oil,  or  4  to  6  ounces  (125-185  c.c.)  of  warm  water  have  a  good  effect 
in  exciting  peristalsis;  or  a  soapsuds  enema,  but  never  of  larger  size  than 
I  quart  (liter).  Olive  oil  injection,  i  pint  to  i  quart  (500  c.c.  to  i  liter), 
at  bedtime,  to  be  retained,  is  useful. 

It  may  be  necessary  to  employ  medication,  such  as  extract  of  cascara, 
I  to  4  grains  (0.065-0.26),  at  bedtime,  or  fluidextract  of  cascara,  i  to  2 
drams  (4.0-8.0),  or  pills,  such  as  the  lapactic,  aloin,  belladonna,  podophyl- 
lin,  phenolax,  purgen  tablets,  regulin,  the  mineral  oils,  etc. 

ACUTE  DILATATION  OF  THE  STOMACH— ACUTE  DIMINISHED 
PERISTOLE  WITH  DILATATION 

Acute  dilatation  of  the  stomach  may  be  defined  as  acute  atony  of  the 
stomach,  with  resulting  acute  motor  insufficiency,  gradually  merging  into 
a  paralytic  condition,  and  accompanied  by  a  distention  of  the  organ  to 
beyond  its  normal  physiologic  limits.  Its  lower  border  extends  to  the 
umbilicus,  or  usually  to  below  this  point,  and  the  stomach  may  even  occupy 
the  entire  abdominal  cavity. 

Brunton,  Fagge,  Boas,  Hemmeter,  notably  Campbell  Thomson,^  and 
Lewis  A.  Conner,^  have  written  on  this  subject.  The  fatal,  or  most  severe 
cases  have  been  reported,  but  the  condition  occurs  quite  frequently.  I 
have  already  referred  to  numerous  types.  ^  Personal  investigation  demon- 
strates that  five  anatomic  types  of  acute  ectasy  exist: 

'  Brochure. 

2  Amer.  Jour.  Med.  Sci.,  March,  1907. 
'  Med.  News,  Aug.  6,  1904. 
26 


402  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

1.  Acute  dilatation  of  the  stomach  alone. 

2.  Acute  ectasy,  which  supervenes  on  an  existing  chronic  dilatation 
(due  to  stenosis  of  the  pylorus).     Thomson  also  reports  one  case. 

3.  Acute  dilatation  of  the  stomach  and  duodenum,  the  most  fatal  type. 

4.  Acute  dilatation  of  the  stomach  engrafted  on  chronic  atonic  dila- 
tation. 

5.  Acute  dilatation  of  the  stomach  and  intestines,  a  mixed  type,  so- 
called  acute  tympanites. 

This  last  is  quite  common,  especially  in  the  acute  infectious  diseases, 
such  as  typhoid  fever  and  pneumonia. 

For  a  complete  description  of  the  theories  of  its  mechanism  and  of  the 
subject,  I  refer  my  readers  to  the  "American  Journal  of  Surgery,"  Novem- 
ber-December, 1908.  Weston  and  the  author  found  that  the  fibrous  at- 
tachment of  the  transverse  duodenum  to  the  diaphragm  (muscle  of  Treitz) 
and  the  pressure  of  the  dilated  stomach  on  the  transverse  duodenum  were 
chief  factors  in  the  production  of  the  gastroduodenal  type  of  dilatation. 
Mesenteric  traction  was  chiefly  produced  by  the  downward  pressure  of 
the  stomach  on  the  intestines,  which  last  exercised  a  countertraction 
against  the  muscle  of  Treitz.  The  collapsed  intestines  were  the  result  of 
pressure. 

Mechanism  of  the  Production  of  Acute  Dilatation  of  the  Stomach. — 
The  nature  of  the  condition  as  stated  is  undoubtedly  an  acute  atony,  with 
acute  motor  insufficiency,  finally  merging  into  a  paralytic  condition.  Many 
factors  in  the  production  of  acute  dilatation  have  been  described,  namely: 

1.  Section  of  jLhe  vagi — -by  Carion  and  Hallion — producing  acute 
dilatation  of  the  stomach,  thus  demonstrating  that  an  injury  or  inflam- 
mation of  these  nerves  may  be  a  cause,  as  in  cerebral  injury,  or  pneumonia 
at  the  base. 

2.  Injury  to  the  dorsal  spine  by  stimulation  of  the  inhibitory  nerves. 

3.  Direct  action  of  the  agent  on  the  musculature  or  its  terminal  nerve- 
filaments;  among  such  may  be  chloroform  or  other  anesthetics,  toxemia 
from  fermentation,  etc. 

4.  Traumatism. 

5.  Spasmodic  stenosis  of  the  pylorus,  due  to  fermentation  or  hyper- 
acidity. 

6.  Acute  gastrorrhea  (Morris);  or  possibly  acute  gastrosuccorrhea 
(Kemp). 

7.  Kelling's  and  Conner's  experiments  on  spasmodic  closure  of  the 
cardia,  and  the  demonstration  of  kinks  in  various  parts  of  the  duodenum, 
or  of  spasm  of  the  pylorus. 

8.  Rotation  of  the  pylorus. 

9.  Kelling's  and  Braun's  experiments,  demonstrating  that  acute  dila- 
tation of  the  stomach  is  a  paralytic  condition  by  producing  it  with  animals 
under  deep  narcosis. 

10.  Rotation  at  junction  of  cardia  and  esophagus. 

11.  Toxemia  from  infection,  as  from  the  toxins  of  typhoid,  pneumonia, 
etc.;  or  auto-intoxication  from  improper  diet,  causing  gastro-intestinal 
dilatation  during  the  course  of  these  diseases.  Dietary  indiscretions  are 
the  causes  of  acute  ectasy  of  the  milder  types  which  I  shall  shortly  describe. 


ACUTE    DILATATION    OF    THE    STOMACH 


403 


12.  Obstruction  of  the  transverse  duodenum  is  one  of  the  frequent  causes 
so  far  found  in  the  fatal  cases,  producing  acute  gastroduodenal  dilatation, 
the  most  dangerous  type.  There  are  a  number  of  causes  given  for  this 
condition,  notably: 

(a)  Mesenteric  obstruction  of  the  duodenum  from  mesenteric  traction. 
Out  of  69  fatal  cases,  19,  or  27.5  per  cent.,  Conner  states  were  caused  by 
this,  and  probably  33  to  50  per  cent,  is  nearer  the  figure,  according  to  his 
view.'  Albrecht  first  called  attention  to  its  condition,  performing  numer- 
ous experiments. 

(b)  Pressure  from  the  distended  stomach  on  the  transverse  duodenum, 
producing  complete  obstruction,  is  most  frequently  the  cause  in  my  belief. 

(c)  The  firm  fibrous  band  (muscle  of  Treitz)  attaching  the  transverse 
duodenum  to  the  crus  of  the  diaphragm, 
a    factor    hereafter    noted    and    demon- 
strated by  Dr.  Weston  and  myself,  is  also 
an  important  factor. 

Regarding  mesenteric  traction,  Con- 
ner further  beheved  that  the  conditions 
essential  for  this  were  the  dorsal  position, 
an  empty  intestine,  and  a  mesentery  of 
such  length  that  the  intestine  can  slip 
into  the  pelvis  and  yet  hang  free.  He 
holds  that  fasting,  purges,  and  enemas 
after  operation  have  a  possible  bearing. 
The  author  notes  that  acute  dilatation 
of  the  stomach,  however,  does  not  occur 
more  frequently  with  enteroptosis  as 
might  be  expected  if  that  theory  were 
correct. 

13.  Obstruction  of  the  pylorus  from  a  gall-stone  which  had  ulcerated 
into  the  intestine  and  thence  into  the  stomach  has  been  reported  by 
Babcock.^ 

Accessory  factors  are  suggested,  such  as  a  lax  abdominal  wall,  pressure 
from  weight  of  hepatized  lungs  (in  pneumonia),  coughing  and  laughing 
paroxysms,  lordosis,  or  an  abnormal  position  of  the  duodenum.  It  gen- 
erally crosses  the  third  lumbar  vertebra;  the  fourth  is  the  most  prominent, 
and  more  pressure  would  be  exercised  at  this  point. 

Clotted  blood  behind  the  transverse  duodenum  was  a  cause  in  one  case. 

On  the  other  hand,  some  believe  the  stomach  dilatation  is  the  primary 
factor,  and  the  mesenteric  constriction  is  produced  secondarily  by  the 
stomach  forcing  down  the  intestines. 

T.  Satterthwaite  and  the  author  studied  the  efifects  of  acute  gastric 
distention  on  the  pulse  and  respiration  by  artificially  distending  the  stom- 
achs of  patients  with  carbonic  acid  gas  and  taking  the  blood-pressure 
before,  during,  and  after  the  experiment.  In  Fig.  202  is  illustrated  the 
result  in  one  of  our  cases. 


202. — Experiment:  Acute  dila- 
tation by  CO2  distention. 


*  N.  Y.  Med.  Jour.,  June  7,  1913. 


404  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

Physician Position  dorsal. 

Pulse  Pressure        Respiration  Pulse 

Before  distention 72  135  18  Slightly   irritable    (to- 

bacco). 

After  distention 86  120  24  Irregular      in      force; 

some       intermission 
in  the  beats. 

Pain  under  the  sternum  and  over  the  abdomen,  sensation  of  suffoca- 
tion and  of  flushing  of  the  face,  nausea,  and  discomfort  accompany  the 
acute  distention.  The  stomach  extends  to  one  finger-breadth  below  the 
umbiUcus;  in  all  a  distention  of  t,^  fingers'  breadth. 

Aspiration  of  the  contents  relieved  the  symptoms.  These  facts  em- 
phasize the  danger  of  overdistention  of  the  stomach  with  carbonic  acid 
gas  for  testing  the  position  of  the  organ  in  patients  with  cardiac  or  pul- 
monary disease,  or  in  old  age,  also  the  danger  of  acute  ectasy  as  a  compli- 
cation. Moreover,  the  true  dimensions  of  th'e  stomach  may  not  be 
obtained  by  the  method  of  carbonic  acid  gas  distention. 

In  this  connection,  the  author  feels  that  he  must  briefly  refer  to  an 
article^  entitled  "The  Non-entity  of  Acute  Dilatation  of  the  Stomach," 
to  which  some  physicians  have  referred.  As  a  sample  the  writer  states, 
"But  as  has  been  already  intimated,  nothing  short  of  crushing  and  stretch- 
ing of  the  musculature  should  cause  acute  dilatation,  and  such  causes  do 
not  exist."  Such  productions,  when  taken  seriously  by  the  profession,  I 
feel  do  positive  harm.  The  author  invites  the  writer  of  this  article  or  any 
skeptic,  to  test  on  himself  the  experiment  with  tartaric  acid  and  bicarbonate 
of  soda.  Ingest  separately  about  3  drams  (12.0)  each  of  soda  bicarbonate 
and  tartaric  acid  in  8  ounces  (250  c.c.)  of  water  and  observe  the  results. 
A  physician  or  nurse  should  be  at  hand  with  a  stomach-tube. 

Etiology  of  Acute  Ectasy. — It  may  be  primary  or  secondary.  The 
causes  are  as  follows:  Indigestible  food;  infectious  diseases,  such  as  ty- 
phoid, pneumonia,  acute  tuberculosis,  and  scarlatina;  during  convalescence 
from  long-continued  disease,  as  chronic  tuberculosis,  hip-disease,  pneu- 
monia, typhoid,  sarcoma,  and  anemia;  injury  to  the  head  or  spine;  trau- 
matism to  the  abdomen;  postoperative,  in  which  manipulation  of  the 
viscera,  shock,  uremia,  sepsis,  and  the  anesthetic  are  factors;  one  case 
after  gastro-enterostomy  reported  by  the  author;  retroperitoneal  abscess; 
disease  and  deformity  of  the  spine,  lordosis,  etc.;  application  of  plaster 
jacket  in  spinal  deformity;  paroxysm  of  laughing  supposedly  (true  cause 
undiscovered).  Toxemia  or  auto-intoxication  are,  therefore,  factors  in 
many  cases. 

Age. — It  may  occur  from  infancy  to  old  age.  Three-fourths  of  the 
cases  are  developed  during  adolescence  or  early  adult  life  (ten  to  forty 
years). 

Sex. — Is  about  equally  divided. 

Clinically,  we  may  classify  acute  dilatation  of  the  stomach  into  cases 
presenting  various  clinical  types,  in  this  sense  atypic,  and  into  the  typic 
cases,  which  are  usually  described.  The  mild  atypic  cases  will  be  first 
described. 

^  Med.  Rec,  Nov.  5,  1910. 


ACUTE   DILATATION   OF    THE   STOMACH 


405 


Clinical  Types  of  Acute  Ectasy. — I  shall  briefly  refer  to  these  cases 
(milder  types)  which  have  already  been  fully  reported  by  me.^  One  of 
my  eminent  confreres  referred  to  thfe  types  now  to  be  described  as 
probably  aeorophagy,  which,  mildly  speaking,  seems  untenable. 


A/onrtal  "Position 


-V  ^yfcu/a  Dilatation 


Fig.  203. — Acute  dilatation  of  the  stomach  during  epileptic  attack. 

I.  Cases  of  Acute  Dilatation  of  the  Stomach  with  Symptoms  Pointing  to 
the  Nervous  System. — Convulsions  in  Infants  and  Young  Children. — Auto- 
intoxication is  the  cause.     I  have  seen  a  case  in  an  infant  two  years  of  age 


Fig.  204. — Acute  dilatation  of  the  stomach  in  migraine,  August  29,  1902.  Borders 
of  stomach:  1,  August  16;  2,  August  29,  in  the  morning;  3,  August  29,  in  the  evening; 
4,  August  30,  in  the  morning;  5,  August  30,  in  the  evening;  6,  August  31,  in  the  morning. 

in  which  the  stomach  extended  2  inches  below  the  umbilicus.  Vomiting 
of  bread  and  curds  occurred,  with  immediate  cessation  of  convulsions^  and 
return  of  the  stomach  to  normal  position.  Repeated  attacks  may  lead 
to  chronic  ectasy  or  epilepsy. 

^  Amer.  Jour,  of  Surg.,  Nov.-Dec,  1908. 
-  No  aerophagy  in  this  case. 


4o6 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Epilepsy. — Mangelsdorf^  has  demonstrated  acute  ectasy  during  the 
convulsive  seizure  and  the  gradual  return  to  normal  position  (Fig.  203). 

Migraine. — The  same  author  rioted  similar  conditions  during  attacks 
of  migraine  (Fig.  204),  and  reports  500  cases  in  epilepsy  and  migraine. 

Lauder  Brunton^  noted  transitory  dilatation  in  sick  headache. 

Tetany. — Broadbent^  describes  a  case  of  acute  ectasy  with  tetany,  which 
ended  in  recovery. 


^ 


Fig.  205. — Acute  dilatation  of  stomach  with  tachycardia. 

Chorea. — Acute  ectasy  has  been  reported  as  a  terminal  event  in  chorea.^ 
3.  Acute  Ectasy  Producing  Acute  Cardiac  Symptoms. — Tachycardia. — • 
Girl,  aged  twenty-one,  with  chronic  endocarditis,  excellent  compensation, 
no  gastric  disturbances.  Tachycardia,  210  beats  per  minute,  followed 
dietary  indiscretion.  Acute  ectasy  was  found  as  in  Fig.  205.  Emesis  oc- 
curred, the  stomach  contracted  to  normal  size,  and  the  tachycardia  ceased. 
The  patient  suffered  from  several  attacks,  but  has  had  no  further  trouble 
since  she  has  exercised  care  in  diet. 

Pseudo-angina  Pectoris. — Female,  aged  sixty-five,  suffered  from  attacks 
of  pseudo-angina,  following  dietary  indiscretions,  at  times  consciousness 

^  Rose  and  Kemp,  Atonia  Gastrica. 

2  AUbutt's  System  of  Medicine,  vol.  iii,  p.  392. 

*  Practitioner,  1908. 

^  Lancet,  April  19,  1890. 


ACUTE    DILATATION    OF    THE    STOMACH 


407 


was  lost.  A  number  of  attacks  occurred  and  in  every  instance  acute 
ectasy  was  present,  as  in  Fig.  206.  Emesis  relieved  both  the  dilatation 
and  the  attack.     Ultimate  cure  resulted  from  proper  diet. 

4.  Acute  Ectasy  Complicating  Infectious  Diseases,  Notably  Typhoid  and 
Pneumonia. — The  tympanites  of  typhoid  is  frequently  not  purely  intes- 
tinal. Acute  gastro-intestinal  dilatation  is  by  no  means  rare;  in  fact,  I 
have  found  it  quite  frequent.  Systemic  infection  or  improper  diet  cause 
this  condition.     Acute  gastroduodenal  dilatation  has  been  reported. 

In  the  milder  types  of  acute  gastro-intestinal  dilatation  there  is  often 
no  vomiting.  There  are  cardiorespiratory  symptoms  which  might  suggest 
pulmonary  involvement.  Examination  shows  acute  distention.  Postural 
treatment,^  by  elevation  of  the  head  of  the  bed,  enteroclysis,  and  lavage, 


Fig.  206. — Acute  dilatation  of  the  stomach  with  symptoms  of  pseudo-angina  pectoris. 


will  relieve  the  symptoms.  The  same  mixed  type  of  distention  may  occur 
with  pain  and  shock  and  simulate  perforatioa  After  relief  of  the  disten- 
tion, examination  shows  absence  of  muscular  rigidity  (no  peritonitis). 

In  the  acute  distention  of  typhoid,  with  intestinal  hemorrhage,  lavage 
will  relieve  gastric  distention  and  diminish  intra-abdominal  tension.  I  have 
never  seen  it  recommended. 

Pneumonia.- — We  may  have  the  gastroduodenal  type  of  acute  ectasy, 
of  which  several  cases  are  reported.  The  mixed  type  is  quite  common  and 
constitutes  a  serious  danger.  Undoubtedly,  sudden  heart-failure  has  been 
precipitated  by  this  condition.  The  etiology  and  treatment  are  the  same 
as  in  typhoid  fever.  There  is  greater  danger  to  the  heart  from  the  pressure 
than  from  the  passage  of  the  stomach-tube. 

^  See  Treatment  of  Typhoid  Fever. 


4o8 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


5.  Acute  Eciasy  with  Coprostasis  the  Prominent  Symptom. — Male,  aged 
fifty-five,  following  indiscretions  in  diet,  complained  chiefly  of  coprostasis, 
with  occasional  vomiting.  Constipation  had  been  present  eight  days  when 
I  saw  the  case.  Fecal  impaction  was  present  in  the  sigmoid  and  caput 
coli. 

Frequent  lavage,  enteroclysis,  and  cathartics  relieved  the  condition. 
In  Fig.  207  is  depicted  the  stomach  before  and  after  relief. 

6.  Acute  Dilatation  Supervening  on  Chronic  Ectasy. — Female,  aged 
forty-five,  suffered  from  chronic  ectasy  due  to  pyloric  stenosis  from  ulcer. 


Fig.  207. — Acute  (Jilaiaiioii  ui 


liic  sioiiiacii,   with  constipation  (ten  days'  duration) 
a  prominent  symptom. 


Following  a  dietary  indiscretion,  acute  ectasy  resulted  with  gastrosuc- 
corrhea,  pain,  vomiting,  peristaltic  waves,  constipation,  and  collapse. 

In  Fig.  208  is  shown  the  acute  ectasy,  with  return  to  the  position  of 
chronic  ectasy  after  lavage.  Subsequently  gastro-enterostomy  was  per- 
formed with  a  gain  of  100  pounds  in  the  patient's  weight. 

Symptoms  of  the  Severe  Cases. — This  type  may  occur  after  opera- 
tion (post-operative  dilatation).  The  symptoms  are  characteristic,  and 
are  as  follows: 

Sudden  abdominal  distention,  pain,  tenderness,  excessive  vomiting, 


ACUTE    DILATATION    OF    THE    STOMACH 


409 


constipation,  thirst,  scanty  urine,  and  collapse.     It  has  been  mistaken 
for  intestinal  obstruction,  or  for  peritonitis. 

Onset. — This  is  nearly  always  sudden.  The  patient  may  be  well,  or 
follow  operation,  or  suffer  from  some  illness  taking  its  usual  course, 
when  he  suddenly  complains  of  great  distention,  discomfort,  or  severe 
pain  in  the  abdomen.  This  is  rapidly  followed  by  vomiting,  which  is  the 
most  constant  symptom,  begins  early,  and  generally  persists  throughout 
the. attack.  Rarely  there  may  be  an  intermission  due  to  temporary 
cessation  of  secretion,  or  cessation  of  vomiting  may  be  a  terminal  event, 
the  abdominal  muscles  and  diaphragm  being  no  longer  able  to  expel  the 


Fig.  208. — Acute  dilatation  of  the  stomach  engrafted  on  chronic  dilatation. 


contents.     Cessation  of  vomiting  is,  therefore,  not  always  a  favorable 
symptom. 

The  vomiting  is  profuse,  in  large  amounts,  and  comes  up  in  gulps 
without  straining.  In  the  early  stage  it  may  consist  of  the  gastric  con- 
tents, of  food  in  various  degrees  of  fermentation;  later,  it  becomes  thinner 
and  watery,  and  generally  of  a  greenish  hue.  It  is  often  described  as 
bilious.  It  may  be  brownish,  grayish,  or  even  inky  black;  occasionally 
there  may  be  a  trace  of  blood.  Often  in  the  postoperative  cases  acute 
distention,  pain,  and  greenish  vomiting  are  the  first  symptoms.  The 
vomitus  may  be  sour  or  foul  or  even  (rarely)  feculent  in  odor. 


4IO 


DISEASES    OF    THE    STOMACH   AND    INTESTINES 


Character  of  the  Vomitus. — Various  constituents,  such  as  bile,  diastase 
ferment,  hydrochloric  acid,  lactic  acid,  and  traces  of  blood,  visible  or 
occult,  have  been  found. 

Pain  is  present  in  the  majority  of  cases,  usually  in  the  epigastric  and 
umbilical  regions.  In  the  gastro-intestinal  mixed  cases  at  the  commence- 
ment it  is  more  general  and  acute  from  sudden  distention,  being  suggestive 
of  peritonitis.  Sudden  perforation  may  even  be  suspected.  Later  there 
is  a  feeling  of  distention,  not  so  acute,  with  accompanying  cardiorespiratory 
symptoms.     It  differs  from  the  continuous  pain  of  acute  obstruction. 

Tenderness  occurs  in  some  cases.  Muscular  rigidity  is  absent.  The 
urine  becomes  scanty  and  nearly  suppressed  during  the  last  twenty-four 
hours.  Anuria  is  diagnostic  of  obstruction  high  up  in  the  intestinal  tract, 
and  does  not  occur  with  obstruction  of  the  large  intestine.  It  has  been 
mistaken  for  uremia.  The  temperature  is  usually  normal  or  subnormal, 
unless  the  patient  has  preceding  fever.     Thirst  is  marked.     Hiccough  may 

occur  as  a  terminal  symptom,  as  may  also  de- 
lirium. General  muscular  cramps  occurred  in 
one  case;  and  Broadbent  reports  a  case  of 
tetany. 

Physical  Signs. — In  the  gastric  or  the  gas- 
troduodenal  type  there  is  distention  of  the 
abdomen,  but  the  swelling  is  not  uniform;  it 
chiefly  fills  the  left  half  and  lower  part  of  the 
abdomen,  and  the  right  hypochondrium  ap- 
pears to  be  flattened.  There  is  often  swelling 
in  the  epigastrium. 

The  following  is  of  service:  Draw  a  line 
from  the  tip  of  the  ensiform  to  the  junction  of 
the  middle  and  outer  third  of  Poupart's  liga- 
ment (Fig.  2og).  The  distention  usually  lies 
to  the  left  and  below  this  oblique  line.  Occa- 
sionally it  appears  more  below  the  navel  and 
sometimes  there  is  general  distention,  particularly  in  gastro-intestinal 
dilatation. 

Splashing  sounds  (su^cussion)  and  the  sense  of  fluctuation  are  an  aid 
in  some  cases.  They  are  not  always  present  in  the  early  period,  when  there 
is  chiefly  gas  in  the  organ.  They  occur  below  the  level  of  the  umbilicus. 
Percussion  will  show  the  resonance  increased,  but  will  be  interfered 
with  when  there  is  much  fluid.  It  is  important  when  the  splash  is  absent. 
Peristaltic  waves  of  contraction  occur  very  seldom.  They  are  found  only 
before  complete  paresis  takes  place,  or  in  the  acute  cases  engrafted  on  the 
stenotic  type  of  chronic  dilatation. 

The  general  symptoms  are  those  of  collapse,  a  rapid  and  small  pulse, 
frequent  respiration,  a  clammy  skin,  and  subnormal  temperature. 

Duration  of  the  Attacks. — The  duration  of  the  attack  depends  on  its 
severity  and  type  of  case.  In  my  case  of  tachycardia  it  lasted  less  than 
an  hour.  In  the  mixed  cases  it  depends  on  the  treatment  accorded  by  the 
physician. 

Among  the  severe  cases,  one  case  of  Conner's  died  within  three  hours 


Fig.  209. — Line  drawn 
from  ensiform  to  Poupart's 
ligament. 


ACUTE    DILATATION    OF    THE    STOMACH 


411 


after  the  onset  of  the  pain,  which,  with  distention,  was  the  first  symptom. 
There  was  no  vomiting.  Several  cases  died  within  twenty-four  hours,  and 
sixteen  days  was  the  longest  duration.  The  average  was  about  five  days. 
Some  cases  recur,  or  several  weeks  may  elapse,  before  the  dilatation  entirely 
disappears. 

Prognosis.— In  the  severe  cases  it  has  been  extremely  bad,  being  a 
most  formidable  condition.  There  is  a  72  per  cent,  death-rate  recorded. 
In  reality  many  cases  occur,  and  with  our  present  knowledge  with  proper 
treatment,  the  mortality  should  be  comparatively  small. 

Morbid  Anatomy. — The  postmortem  appearance  of  the  stomach  is 
quite  characteristic,  being  cyhndric  and  bent  into  a  horseshoe  or  V  shape. 
The  cardiac  portion  is  the  longer  (Fig.  210). 

The  walls  of  the  stomach  are  distended  and  thinned.  A  large  amount 
of  elasticity  is  retained,  as  shown  by  the  shrinking  that  takes  place  after 
the  distending  force  is  removed.^  The 
stomach  may  occupy  the  entire  ab- 
domen or  even  reach  into  the  pelvis. 
It  has  been  mistaken  on  operation  for 
cyst  of  the  pancreas.  Its  color  may  be 
purplish-red,  gray,  or  bluish-white. 

Microscopic  Examination. — This  has 
been  made  in  a  few  cases.  There  was 
thinning  of  the  musculature  and  no 
definite  microscopic  changes  were  noted, 
though  in  some  there  were  small  hemor- 
rhages. 

Duodenum. — In  a  large  number  of 
cases — over  50  per  cent.  (Conner) — a 
part  or  the  whole  of  the  duodenum 
shared  in  the  dilatation;  in  many  the 
distention  stopping  where  the  mesen- 
tery crossed.  Kinks  have  also  been 
found  in  the  duodenum.  The  coils  of 
the  intestines  are  flattened  and  col- 
lapsed in  the  pelvis. 

Diagnosis. — One  should  always  think  of  the  possibility  that  tachy- 
cardia, convulsions,  epilepsy,  migraine,  anginoid  symptoms,  increased 
cardiac  and  respiratory  rapidity,  and  even  tetany  may  occur  with  acute 
ectasy.  Sudden  gastro-intestinal  dilatation  is  quite  frequent  in  typhoid 
and  pneumonia.  Often  vomiting  is  absent  at  first  in  the  milder  cases,  and 
the  chief  symptom  pointing  to  the  abdomen  is  distention.  At  times  there 
may  be  acute  pain  in  typhoid,  simulating  perforation,  but  muscular  ri- 
gidity is  absent.  Cardio-respiratory  symptoms  may  occur.  Examination 
in  every  case  should  be  made  by  percussion,  the  splashing  sound,  and  espe- 
cially by  lavage,  if  there  is  any  doubt. 

Intestinal  irrigation  (recurrent)  will  often  relieve  distention  when 
present,  and  aid  in  diagnosis. 


Fig.  210. — Postmortem  appearance 
of  acute  dilatation  of  the  stomach. 


1  McEvitt,  N.  Y.  State  Jour,  of  Med.,  July,  igo6. 


412  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Postnarcotic  vomiting  may  become  gradually  persistent,  and  this  should 
be  looked  on  with  suspicion. 

Pain,  tenderness,  distention,  continuous  vomiting  of  bilious  appear- 
ance are  suggestive,  especially  with  collapse,  rapid  and  feeble  pulse,  urinary 
suppression,  and  obstinate  constipation. 

In  the  severe  cases  there  may  be  occasionally  no  vomiting  and  no  pain, 
but  only  acute  distention  and  some  diarrhea.  The  use  of  the  stomach- 
tube  and  determining  the  position  of  the  stomach  before  and  after  its  em- 
ployment are  of  value  in  all  cases. 

//,  after  lavage,  the  distention  disappears  and  there  is  no  distention  of 
the  intestines,  or  only  slight  tympanites  in  the  colon,  the  acute  dilatation 
is  of  the  stomach,  or  of  the  gastroduodenal  type. 

If  intestinal  distention  persists,  the  dilatation  is  of  the  mixed  type. 

If  all  the  tympanites  is  relieved  by  enteroclysis,  subsequent  examina- 
tion will  determine  the  stomach  not  to  be  dilated. 

The  presence  of  pancreatic  juice,  absence  of  fecal  vomiting,  and  pres- 
ence of  bile  show  the  gastroduodenal  type.  This  is  especially  true  if  the 
abdominal  posture  affords  relief.  Bile,  however,  may  be  present,  with 
acute  gastric  distention  alone. 

True  stercoral  vomiting  shows  obstruction  lower  down,  and  muscular 
rigidity  is  a  symptom  of  peritonitis. 

Treatment. — Prophylaxis. — Rapidity  in  operating,  the  minimum 
amount  of  manipulation  of  the  viscera,  a  minimum  quantity  of  anes- 
thesia, and  care  in  feeding  after  operation  are  important.  Distention 
following  operation  should  receive  immediate  treatment  by  lavage  and 
enteroclysis.  These  methods  will  prevent  subsequent  acute  dilatation  of 
the  stomach  and  should  be  advocated  in  all  cases.  Open  the  bowels  early 
after  operation. 

The  aboUtion  of  milk-diet  in  typhoid  fever,  pneumonia,  and  acute 
infectious  diseases  is  advisable,  with  the  substitution  of  broths,  strained 
soups  of  various  kinds,  as  barley,  rice,  and  gruels.  If  the  patient  has  had 
an  attack,  then  the  conditions  of  the  gastric  secretion  should  be  investi- 
gated, irregularities  corrected,  and  proper  diet  instituted. 

In  every  case  of  acute  ectasy  the  stomach  should  be  immediately 
evacuated  by  lavage.  It  is  an  error  to  wait  until  the  symptoms  appear 
marked,  or  until  the  patient  vomits,  before  lavage  is  instituted.  The 
stomach  may  redistend  in  the  severe  cases.  Lavage  immediately  on  the 
appearance  of  distention. 

It  is  advisable  to  repeat  lavage  within  two  hours  or  at  times  in  three 
hours,  and  thereafter  every  four  to  six  hours,  during  the  first  twenty-four 
hours,  depending  on  the  physical  signs  and  symptoms.  It  may  be  neces- 
sary to  perform  it  more  frequently.  At  times  it  must  be  carried  out  for 
some  days.     It  is  safer  to  err  on  the  side  of  frequency. 

Bassler  has  devised  a  method  for  continuous  drainage  of  the  stomach. 
He  passes  a  small  stomach-tube  through  one  nostril  into  the  stomach. 
It  is  fastened  to  the  wings  of  the  nostrils  with  adhesive  strapping.  To  the 
stomach-tube,  by  means  of  a  small  glass  joint,  a  long  tube  with  lavage 
funnel  is  attached.  The  funnel  lies  at  a  level  below  the  bed.  By  this 
method  a  siphon  action  is  exerted  to  continuously  drain  -the  stomach  of 


ACUTE   DILATATION    OF    THE    STOMACH  413 

gas  and  fluid,  and  the  tube  is  always  in  situ  for  lavage.  The  writer  finds 
that  the  small  nasal  feeding  tube  attached  by  means  of  a  large  medicine 
dropper  to  a  larger  tube  and  funnel  is  often  more  comfortable  and  yet 
practical.  Lavage  can  be  given  also  through  this  tube.  Some  patients, 
however,  object  to  this  method  or  it  may  cause  irritation  so  it  cannot  be 
retained. 

No  food  or  drink  shovld  be  given  by  mouth.  For  severe  thirst,  saline 
enemata,  proctoclysis,  or  even  hypodermoclysis  may  be  administered. 
They  are  also  eflScient  in  the  collapse,  and  saline  or  mediate  infusion  may 
be  required.  Rectal  feeding  must  be  kept  up  for  several  days  until 
symptoms  disappear. 

If  there  is  intestinal  distention,  continuous  recurrent  rectal  irrigation 
with  normal  saline  solution  at  i2o°F.  is  of  value.  It  is  advisable  to  pro- 
mote peristalsis  as  soon  as  possible.  Unless  hemorrhage,  peritonitis,  or 
appendicitis  complicate  (as  might  occur  in  typhoid),  or  there  be  a  suspicion 
of  a  true  intestinal  obstruction,  after  washing  the  stomach  with  plain  water, 
in  which  milk  of  magnesia,  2  ounces  (60.0),  has  been  dissolved,  I  give 
calomel,  3  to  5  grains  (0.2-0.3),  ^^  water  yi  ounce  (15.0),  directly  through 
the  stomach- tube  before  removal;  and  a  saline  cathartic  by  the  same 
method  four  to  six  hours  later. 

In  some  cases  I  have  given  by  preference  a  high  enema  of  4  ounces 
(125  c.c.)  of  a  saturated  solution  of  magnesium  sulphate  two  hours 
after  lavage.  This  may  be  preferable,  lest  the  patient  vomit  the  saline 
cathartic. 

Tincture  of  belladonna  is  useful.  It  lessens  the  secretion,  relaxes 
pyloric  spasm,  and  has  an  excellent  effect  on  the  atony.  It  should  be 
given  in  5-  to  lo-gtt.  (0.296-0.592)  doses  on  the  tongue,  with  strychnin, 
Hq  to  3'^o  grain  (0.00108-0.00212),  every  four  to  six  hours  by  hypodermic 
injection.  The  latter  stimulates  the  musculature,  the  heart,  and  respira- 
tion. Atropin,  J^foo  grain  (0.00065)  to  }4o  grain  (0.00130)  may  be 
substituted  hypodermically  for  belladonna. 

Physostigmin  sulphate  (eserin),  ^foo  grain  (0.00065),  ^^^  been  recom- 
mended to  promote  evacuation  of  the  bowel.  I  have  recently  employed 
yiQ  grain  (0.0013)  every  two  hours  for  three  doses  with  success.  It  is 
well  to  arrange  to  give  strychnin,  >{oo  to  %q  grain  (0.00065-0.00108),  to 
guard  the  eserin.  Pituitary  extract  (Vaporole — Burroughs,  Wellcome  & 
Co.),  I  c.c.  by  hypodermic,  is  of  value  both  to  promote  muscular  contrac- 
tion of  the  gastro-intestinal  tract,  to  stimulate  action  of  the  bowels  and 
also  to  improve  the  pulse.  Elaterin,  gr.  3^o>  is  also  of  service  to  move 
the  bowels  by  hypodermic.  Hormonal^  (peristaltic  hormone)  has  been 
suggested,  by  intra-muscular  or,  preferably,  by  intravenous  injection,  for 
the  paretic  condition  of  the  intestines.  Average  dose,  20  c.c,  with 
normal  saline  solution  at  i2o°F. 

Rectal  electric  recurrent  irrigations  of  the  bowels  are  eflacacious  for 
obstinate  constipation.  The  writer  has  a  recurrent  irrigator  with  battery 
attachment. 

The  second  most  important  therapeutic  measure  is  postural  treatment. 
The  position  of  the  patient  depends  on  the  anatomic  t)fpe  of  the  dilatation. 
*  Medizin  Klinik,  19 10,  No.  11. 


414  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

1.  The  semi-oblique  or  nearly  sitting  position,  the  head  of  the  bed  is 
blocked  up  as  in  the  illustration  under  Typhoid  Fever.  The  patient  lies 
on  an  inclined  plane.  This  is  of  value  in  the  acute  gastro-intestinal  (or 
mixed)  type,  with  general  abdominal  distension,  so  frequent  in  typhoid  or 
pneumonia,  where  the  cardiac  and  respiratory  symptoms  are  pronounced 
from  abdominal  pressure.  By  elevation  of  the  head  of  the  bed  in  one  severe 
case  of  typhoid  the  tympanitic  area  in  the  thorax  lowered  4  inches,  and 
the  pulse  and  respiration  dropped  20  points  each. 

A  fatal  issue  may  result  from  pressure-effects  on  the  heart  and  lungs 
with  this  type. 

Frequent  lavage  and  enteroclysis  should  be  instituted  in  these  cases, 
and  later  milk-free  diet,  substituting  soups  and  broths. 

This  position  would  be  incorrect  in  the  gcLstroduodenal  type  of  dilata- 
tion. 

2.  Elevation  of  the  foot  of  the  bed  to  relieve  pressure  on  the  duodenum. 
The  objectionable  feature  is  the  danger  from  pressure  on  heart  and  lungs 
if  the  stomach  should  begin  to  redilate. 

3.  In  the  acute  gastroduodenal  type  the  lateral  position,  on  the  right  or 
left  side,  has  relieved  the  symptoms.     The  patient  recovered. 

4.  The  abdominal  position  {patient  lying  on  the  belly)  is  the  best  method 
to  treat  the  acute  gastroduodenal  type,  or  for  acute  dilatation  of  the 
stomach  alone. 

That  this  position  affords  relief  seems  to  me  to  show  quite  conclusively 
that  the  gastroduodenal  type  of  obstruction  is  caused  chiefly  by  the  stomach 
pressure  on  the  transverse  duodenum. 

Baumler  kept  the  patient  fifteen  minutes  in  the  knee-chest  position  in 
each  two  hours;  the  balance  of  the  time  on  the  belly. 

Operations. — These  have  not  generally  proved  successful.  Among 
those  performed  or  suggested  were: 

The  stomach  opened  and  evacuated,  and  gastro-enterostomy.  Gas- 
tric fistula  might  be  tried.  A  kink  at  the  duodenojejunal  junction  was 
relieved  in  one  case,  and  the  patient  recovered. 

Recovery  has  also  been  reported  after  one  case  of  gastro-enterostomy. 

Frequent  lavage,  combined  with  postural  treatment,  enteroclysis,  and 
securing  bowel  action  as  soon  as  possible  are  indicated.  Food  and  drink 
should.be  interdicted.  Relieve  thirst  by  enemata  of  saline  solution  and 
by  proctoclysis,  and  hypodermoclysis  in  extreme  cases. 

CHRONIC    DILATATION    OF    THE    STOMACH— DIMINISHED  PERISTOLE 
WITH  CHRONIC    DILATATION 

{Synonyms. — Ectasy;  Ectasia  Ventriculi;  Gastrectasy;  Ischochymia — Einhorn;  Motor 
InsuflSciency  of  the  Second  Degree — Boas) 

The  term  "dilatation  of  the  stomach"  is  employed  for  descriptive 
purposes,  but  in  view  of  the  existence  of  an  acute  type  of  dilatation  of 
the  organ,  chronic  dilatation  of  the  stomach  would  seem  a  preferable 
nomenclature. 

Definition. — How  may  dilatation  of  the  stomach  be  defined?  Is  it  to 
be  measured  by  the  capacity  of  the  stomach  alone  or  by  the  increased 


CHRONIC    DILATATION    OF    THE    STOMACH 


415 


capacity  plus  the  alteration  of  its  functions?  The  latter  is  correct.  The 
capacity  of  the  normal  stomach  is  extremely  variable.  Ziemssen  has 
shown  that  a  stomach  may  be  normal  and  only  contain  8  ounces  (250  c.c), 
whereas  another  stomach,  also  normal,  may  possess  a  capacity  of  2  quarts 
(liters).  The  large  stomach  ("megalogastria"),  at  times  found  during  a 
physical  examination,  produces  no  symptoms.  This  may  be  congenital, 
or  acquired  by  large  eaters  or  by  those  who  live  on  a  vegetable  diet.  Such 
cases,  however,  can  readily  develop  atony.  As  long,  however,  as  the  func- 
tions of  the  stomach  are  normal,  we  cannot  regard  the  conditions  met  with 
as  pathologic,  and  hence  cannot  consider  that  dilatation  exists. 

As  already  described,  the  lower  border  of  the  normal  stomach  when 
distended  with  food  or  liquid  lies  from  iH  to  2  fingers'  breadth  above  the 
level  of  the  umbilicus.  Examination 
of  normal  subjects,  complaining  of  no 
symptoms,  will  frequently  show  that  the 
stomachs  are  abnormally  large,  or  in 
an  abnormal  position.  Such  cannot  be 
considered  pathologic.  If  it  descends 
to  nearly  the  level  of  the  umbilicus,  to 
its  level  or  below  it,  and  symptoms  ac- 
company it,  we  must  consider  the  organ 
dilated. 

One  must  not  commit  the  error  of 
mistaking  gastroptosis  for  dilatation. 
With  gastroptosis  the  upper  border  of 
the  stomach  descends  as  well  as  the 
lower  border,  and  there  are  movable 
kidney  and  enteroptosis.  There  are 
varying  degrees  of  gastroptosis. 

The  prolapsed  stomach  may,  in  ad- 
dition, be  dilated.  With  dilatation, 
the  upper  border  of  the  stomach  does 
not  descend,  but  maintains  its  relation 
to  the  diaphragm,  and  the  stomach  is 
dilated  chiefly  in  the  direction  to  which  Fig.  211.— Dilatation  of  the  stomach, 
the  greatest  force  is  applied,  downward 

and  laterally.  The  muscular  fibers  first  elongate  in  the  vertical  direction 
and  the  distance  between  the  lesser  and  the  greater  curvature  is  in- 
creased. Dilatation  may  also  ensue  in  the  transverse  and  anteropos- 
terior dimensions,  and  the  pylorus  may  be  a  little  further  to  the  right 
and  in  a  slightly  lower  plane,  but  the  lesser  curvature  maintains  its  re- 
lation to  the  diaphragm,  and  this  is  the  differential  point  between  dila- 
tation and  gastroptosis  (Fig.  211). 

There  is  confusion  as  to  the  terms  "atony,"  "ectasy,"  and  "motor 
insufficiency,"  as  they  are  often  used  interchangeably  by  different  authors. 

Atony  of  the  stomach  may  be  defined,  as  already  stated,  as  a  loss  of 
tone  or  contractile  power  of  the  muscles  of  the  stomach,  so  that  the  organ 
does  not  contract  about  its  contents,  with  a  resulting  motor  insufficiency 


4l6  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

{inability  to  expel  its  contents  within  the  normal  limit  of  time).  This  con- 
dition has  not  progressed  to  dilatation. 

Ectasy  may  be  defined  as  dilatation,  an  enlargement  of  the  stomach 
permanent  in  character,  combined  with  motor  insuflBiciency.  With  the 
atonic  type  of  ectasia,  there  is  motor  insuflSciency. 

Relative  Motor  Insufficiency, — When  there  is  dilatation  of  the  stomach 
due  to  obstruction  at  the  pylorus,  the  motor  power  of  the  stomach  is  not 
sufficient  to  expel  the  stomach-contents  within  normal  time  limits.  This 
is  spoken  of  as  insufficiency. 

This  should  be  considered  a  relative  insufficiency,  as  in  this  type  the 
musculature  of  the  stomach  is  hypertrophied,  especially  at  the  pyloric 
end,  and  the  contractile  power  is  often  increased,  but  not  sufficiently  to 
expel  the  contents  past  the  obstruction  within  the  normal  time. 

In  the  dilated  stomach  without  pyloric  obstruction  we  have  the  true 
atony  of  the  musculature,  with  varying  degree  of  motor  insufficiency. 

Some  claim  that  stenosis  exists  in  all  cases  of  dilatation  of  the  stomach, 
but  it  is  easy  to  demonstrate  that  there  are  two  distinct  t>q)es  of  chronic 
dilatation  of  the  stomach  differing  in  symptoms  and  pathologic  findings: 

(i)  The  atonic  type  of  chronic  dilatation  of  the  stomach.  (2)  The 
stenotic  (obstructive)  type  of  chronic  dilatation  of  the  stomach.  Radio- 
graphs also  clearly  demonstrate  the  difference  between  these  conditions. 

Differential  Diagnosis. — Atonic  Type. — In  the  atonic  type  there  may 
be  few  or  no  symptoms  pointing  directly  to  the  stomach,  the  patient 
frequently  suffering  from  nervous  symptoms  due  to  auto-iijtoxication  and 
from  intestinal  disturbances.  I  have  seen  many  such  cases  at  the  Man- 
hattan State  Hospital  continue  a  year,  or  even  four  or  five  years,  without 
vomiting.  There  are  no  peristaltic  waves  and  cramp-hke  pains  such  as 
occur  in  the  stenotic  type  followed  by  vomiting;  though  some  may  have 
dyspeptic  symptoms  and  rarely  an  attack  of  vomiting.  The  postmortem 
shows  the  stomach  often  enormously  dilated,  with  thin  walls  and  no  evi- 
dence of  pyloric  stenosis. 

Stenotic  Type. — In  the  stenotic  (obstructive)  type  of  dilatation  dys- 
peptic symptoms  are  marked,  there  are  peristaltic  waves  and  cramp-like 
pains  preceding  vomiting  of  large  quantities  of  gastric  contents,  thirst,  etc. 

In  the  benign  type  of  long  duration  the  patient  often  suffers  markedly 
in  nutrition,  but  the  cachexia  and  other  symptoms  of  malignancy  are 
absent  and  the  disease  runs  a  long  course.  The  postmortem  shows 
considerable  hypertrophy  of  the  musculature  at  the  pyloric  end  of  the 
stomach,  and  elsewhere  thinning  and  dilatation  of  the  muscular  wall  with 
evidence  of  stenosis  at  the  pylorus,  or  constriction  from  some  external 
factor. 


ATONIC  DILATATION   OF  THE  STOMACH.— DIMINISHED  PERISTOLE 
WITH  GASTRIC  DILATATION 

Etiology. — As  causes,  we  may  have  a  primary  reduction  or  loss  of 
muscle  power,  or  impairment  of  it  from  overwork,  for  example,  from  the 
ingestion  of  too  much  material.  It  directly  follows  chronic  atony  of  the 
stomach,  which  is  the  preliminary  stage,  and  hence  there  are  similar 


CHRONIC    DILATATION    OF   THE    STOMACH  4x7 

etiologic  factors,  such  as  wasting  disease,  tuberculosis,  chronic  gastritis, 
heart  disease,  etc. 

Among  other  causes  are  bolting  the  food,  frequent  overloading  the 
stomach,  excessive  drinking  of  large  quantities  of  fluid,  especially  of 
those  containing  much  gas;  it  may  rarely  be  congenital;  it  is  quite  fre- 
quently associated  with  rickets,  in  which  case  gastroptosis  is  quite  often 
also  present.  It  sometimes  follows  repeated  attacks  of  acute  atony  or 
acute  dilatation. 

Nothnagel  traces  back  some  cases  of  chronic  dilatation  to  improper  meth- 
ods of  feeding  during  early  life.  Atonic  ectasy  we  frequently  find  among  the 
insane.  I  have  found  an  enormous  number  of  patients  at  the  Manhattan 
State  Hospital  suffering  from  this  condition,  and  quite  a  number  of  the 
women  with  gastroptosis,  and  frequently  dilatation  associated  with  it. 
Examinations  of  many  hundreds  of  cases  during  the  last  five  years  show 
that  very  few  stomachs  were  in  the  normal  position,  or  possessed  normal 
functions.  Many  of  these  cases  have  never  vomited,  and  in  very  many 
no  special  symptoms  directed  attention  to  the  stomach.  Unquestionably 
the  habit  of  bolting  the  food  common  to  such  patients  is  a  freqiient  cause  of 
ectasy.  Among  the  acute  melancholies,  in  whom  some  ultimate  cures 
resulted,  auto-intoxication,  in  some  cases  the  result  of  ectasy  with  fermenta- 
tion or  putrefaction,  was  the  primary  factor  in  the  production  of  the 
nervous  symptoms.  In  the  epileptic  ward  one  case  suffering  from  dila- 
tation (atonic)  with  gastroptosis,  and  absence  of  free  hydrochloric  acid, 
had  suffered  from  numerous  epileptic  convulsions  both  day  and  night, 
averaging  140  seizures  per  month.  Under  simple  diet,  initial  lavage, 
and  later  diet  and  medication  directed  to  the  gastro-intestinal  tract  alone, 
she  had  no  convulsions  for  two  years  and  a  half,  with  the  exception  of 
one  week,  some  fourteen  months  after  treatment  was  begun,  during  which 
period  she  was  taken  off  diet  and  medication  while  in  the  general  hospital 
ward  with  an  acute  nephritis.  Bromids  were  only  given  two  months  at 
the  commencement  in  small  dosage  to  break  the  convulsive  habit.  At  the 
end  of  three  years  the  patient  was  discharged.  There  were  no  convul- 
sions, and  her  mental  condition  was  apparently  excellent.  I  have  also 
another  case  of  epilepsy  with  atonic  ectasia  and  hypochlorhydria,  who 
has  gone  over  two  years  without  a  seizure  under  gastro-intestinal  treat- 
ment alone. 

Even  in  the  incurable  insane  this  atonic  type  of  dilatation  has  a  direct 
bearing  on  some  of  the  symptoms.  In  a  series  of  13  paretics,  examined 
for  the  late  Dr.  Dent  at  the  Manhattan  State  Hospital,^  I  found  11  cases 
of  atonic  dilatation  of  the  stomach  and  2  cases  of  gastroptosis,  and  in  all 
secretory  derangements  of  the  functions  of  the  stomach;  11  of  these  cases 
had  at  some  time  of  the  day  a  temperature  of  9g.5°F.  and  upward,  in 
one  102. 5°F.  Under  treatment  directed  to  the  gastro-intestinal  tract 
the  temperature  was  lowered  in  all  11  (in  some  to  normal),  the  convul- 
sions, which  were  present  in  5  cases,  were  diminished  in  frequency,  and 
in  one  patient  suffering  from  attacks  of  syncope,  cessation  of  attacks 
followed  treatment. 

1  Proceedings  of  the  American  Psychological  Association,  Sixty-first  Annual  Meet- 
ing, April,  1905;  also  the  Medical  News,  July  8,  1905. 

27 


41 8  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

The  atonic  type  of  ectasy  is  quite  common  in  many  nervous  cases, 
and  is  undoubtedly,  in  some,  the  cause  of  the  auto-intoxication,  and 
the  nervous  condition  is  secondary.  Atonic  ectasy  may,  therefore,  be 
in  many  cases  the  cause  of  various  conditions.  On  the  other  hand,  ectasia 
resulting  from  insufficient  mastication  and  bolting  of  food  among  many 
of  the  nervous  and  insane  may  be  a  factor  in  the  production  of  a  vicious 
circle.  Beer  drinkers  and  diabetics  suflfer  from  this  type  of  dilatation. 
Professional  men,  bankers,  and  brokers,  from  their  irregular  habits  and 
rapid  eating,  are  quite  liable  to  this  form.  The  musculature  of  the 
pylorus,  as  we  know,  is  much  thicker  than  other  parts  of  the  stomach- 
wall,  and  the  latter  naturally  gives  way  and  distends  more  readily.  This 
does  not  constitute,  however,  a  stenosis  at  the  pylorus.  Ultimately, 
however,  the  pylorus  itself  relaxes  in  these  atonic  cases,  which  undoubtedly 
accounts  for  the  usual  absence  of  vomiting  in  these  patients. 

This  type  of  ectasy  is  extremely  common. 

Symptoms  are  at  times  not  particularly  referred  to  the  stomach  at  all, 
and  often  point  to  the  nervous  system,  or  cause  an  exacerbation  of  a  pre- 
existing nervous  condition.  The  patient  is  often  neurasthenic  or  melan- 
cholic, with  the  symptoms  associated  with  these  conditions.  Intestinal 
toxemia  (auto-intoxication)  is  often  present.  I  have  seen  the  lower 
border  of  the  stomach  in  atonic  ectasy  reach  nearly  to  the  symphysis. 
The  following  symptoms  are  generally  associated: 

Constipation  usually  marked,  rarely  diarrhea,  coated  tongue,  fre- 
quently headache,  and  at  times  dyspeptic  disturbances,  such  as  belching 
and  pressure  after  eating,  though  often  these  symptoms  are  absent 
The  symptoms  may  be  those  of  chronic  gastritis. 

In  a  few  cases  of  extreme  dilatation  there  may  be  occasional  vomit- 
ing of  large  quantities  of  fluid.  There  are  no  spasmodic  pains,  no  per- 
istaltic waves,  and  no  marked  vomiting,  as  in  the  stenotic  type.  In  atonic 
ectasia  with  chronic  gastritis,  the  gastric  symptoms  of  the  latter  may  be 
present,  in  addition  to  the  other  symptoms  already  noted.  Occasionally 
there  is  mold  in  the  stomach.  More  rarely  there  may  be  hyperchlorhydria 
with  atonic  ectasy.  I  have  found  a  number  of  such  cases  among  the 
epileptics,  there  being  no  vomiting,  or  at  times  it  may  occur,  but  at  times 
usually  with  no  peristaltic  unrest.  They  suffer  from  the  symptoms  of 
hyperchlorhydria,  motor  insufficiency  is  present,  there  may  be  spasmodic 
pains  and  occasionally  vomiting  of  considerable  severity,  the  vomitus 
being  very  acid.  These  cases,  as  already  noted,  have  been  mistaken  for 
gastrosuccorrhea.  After  lavage,  and  later  by  aspiration  of  the  contents 
of  the  empty  stomach,  one  readily  demonstrates  that  hypersecretion  is 
not  present.  The  symptoms  in  this  type  are  due  to  the  extreme  hyper- 
chlorhydria and  to  spasm  of  the  pylorus  resulting.  Excellent  results  are 
secured  by  lavage  and  by  the  treatment  of  the  hyperchlorhydria.  Most  of 
the  so-called  cures  of  stenotic  ectasia  belong,  I  believe,  to  this  class.  The 
mild  types  belong  to  the  atonic  class,  though  they  might  be  considered 
border-line  cases.  In  the  cases  in  which  cure  results  without  operation, 
organic  changes  at  the  pylorus,  I  believe,  must  necessarily  have  been 
slight,  while  the  severe  cases  with  ultimately  peristaltic  unrest  and  pro- 
gressive  symptoms  should  be  classed  under  stenosis.     These  last  cases 


CHRONIC    DILATATION   OF   THE    STOMACH  419 

which  do  not  rapidly  respond  to  treatment  of  the  h3rperchlorhydria,  should 
be  referred  to  the  surgeon.  Treatment  of  pyloric  spasm  by  Einhorn's 
pyloric  dilator  the  writer  believes  useless. 

Gastric  Contents. — The  gastric  findings  are  variable;  fermentation  is 
quite  frequently  present  and  hypochlorhydria,  or  nearly  complete  ab- 
sence of  free  HCl;  chronic  gastritis,  occasionally  hyperacidity;  mold  has 
been  found,  and  in  cases  with  gastroptosis  and  dilatation  at  Ward's  Island 
I  have  even  noted  achylia. 

The  usual  manifestations  are  toxemic  in  character,  with  intestinal 
fermentation  or  putrefaction  and  indicanuria. 

Course. — The  milder  cases  of  atonic  dilatation  are  quite  amenable 
to  treatment  and  can  be  cured.  The  severe  cases  do  not  run  so  favorable 
a  course,  and  I  have  seen  such  among  the  nervous  and  insane  where 
the  dilatation  extended  nearly  to  the  symphysis.  I  believe  that  in 
this  type,  drainage  by  gastro-enterostomy  with  closure  of  the  pyloric 
ring  is  indicated,  since  lavage  and  diet  are  only  palliative.  In  some 
gastroplication  may  prove  successful. 

In  the  cases  of  ectasia  due  to  benign  stenosis  there  is  at  times,  under 
treatment,  a  temporary  improvement.  The  stomach,  from  an  increased 
hypertrophy  of  the  muscles  and  a  subsidence  of  the  hyperemia  at  the 
pylorus,  may  secure  a  certain  amount  of  compensation  and  empty  its 
contents  fairly  well  for  a  time,  but  usually  the  symptoms  return,  and, 
finally,  resection  of  the  pylorus,  or  gastro-enterostomy-  become  imperative 
in  order  to  save  the  life  of  the  patient.  I  have  known  these  cases  to  drag 
along  twelve  to  fifteen  years  without  operation.  They  become  chronic 
invalids.     Only  by  operative  procedure  can  a  cure  of  the  case  he  accomplished. 

If  the  stenosis  is  malignant,  then  the  course  depends  on  the  extent 
of  the  disease.  Even  in  those  cases  where  removal  cannot  be  undertaken, 
gastro-enterostomy  will  relieve  the  symptoms. 

Obstructive  Type  (Stenotic)  of  Ectasia 

The  stenosis  causing  this  type  of  dilatation  of  the  stomach  may  be  in 
the  gastric  tissue  at  the  pylorus,  or  near  the  pylorus  in  the  duodenum,  or 
it  may  be  external  to  the  stomach — intrinsic  and  extrinsic  causes.  The 
factor  causing  constriction  may  be  benign  or  malignant  in  character, 
which  would  modify  the  clinical  symptoms. 

Etiology. — (i)  Congenital  stenosis  of  the  pylorus  {hypertrophic  stenosis). 

(2)  Acquired  stenosis,  such  as  from  ulcer,  cicatrices  following  burns 
from  acids  or  alkalis;  from  severe  gastritis,  causing  hypertrophy  at  the 
pylorus;  repeated  spasmodic  closure  of  the  pylorus  due  to  hyperacidity 
(spastic  stenosis  due  to  inflammation  or  irritation);  benign  tumors; 
pedunculated  polypi;  adhesions  at  the  pylorus;  external  tumors;  pressure 
from  large  gall-stones  (in  the  gall-bladder);  perigastric  adhesions;  spider- 
web  adhesions  (Morris)  from  the  gall-bladder;  stenotic  hypertrophic 
gastritis  (Boas),  a  fibrous  disease  of  the  pylorus  (linitis  plastica);  sclerosis 
in  the  pyloric  end  of  stomach  (Ottinger);  pressure  from  external  tumor; 
malignant  disease  of  the  pylorus. 

(3)  Stenosis  of  the  duodenum  from  ulcers,  cicatrices,  carcinoma,  external 
compressions,  adhesions,  kinks,  or  diverticula. 


420  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

It  is  the  modern  consensus  of  opinion  that  bile  may  regurgitate  into 
the  stomach  even  if  the  stenosis  is  present  at  the  pylorus,  as  the  cicatricial 
tissue  holds  it  open  in  many  cases;  so  its  presence  or  absence  does  not 
always  aid  us  as  to  locating  whether  the  stenosis  be  pyloric  or  duodenal. 
Continuous  regurgitation  of  bile  and  pancreatic  juice,  however,  is  sug- 
gestive of  obstruction  of  the  duodenum  below  the  common  duct. 

Movable  kidney  I  do  not  believe  has  any  relation  to  ectasy,  but  when 
associated  with  so-called  dilatation,  it  can  be  demonstrated  that  the 
latter  is  really  a  gastroptosis. 

Pathology. — In  the  stenotic  type,  the  musculature  at  the  pyloric  end 
of  the  stomach  is  much  thickened;  the  fundus  is  much  thinner  than  normal. 
The  pathologic  findings  at  the  pylorus  vary  according  to  the  cause  of  the 
stenosis.  The  intestines  are  pushed  downward  and  the  liver  slightly 
upward  when  marked  ectasy  is  present. 

Symptoms. — The  symptoms  of  dilatation  of  the  stomach  due  to  pyloric 
stenosis  are  quite  characteristic,  but  are  modified  if  the  condition  is  can- 
cerous, or  in  the  special  type  described  by  R.  T.  Morris,  spider  adhesions 
with  hemorrhage. 

Congenital  Stenosis  of  the  Pylorus. — The  symptoms  oj  congenital  stenosis 
of  the  pylorus  are  rather  acute  in  their  progressive  severity.  They  usually 
come  on  directly  after  the  birth  of  the  infant  or  in  the  second  or  third 
week,  depending  on  the  degree  of  stenosis.  The  condition  is  most  readily 
confounded  with  a  rapidly  progressing  marasmus.  There  are  present: 
wasting,  the  infant  rapidly  losing  weight,  projectile  vomiting,  visible 
gastric  peristaltic  waves,  non-fecal  and  no  curdled  bowel  movements,  with, 
in  some  cases,  a  palpable  tumor  mass  in  the  region  of  the  pylorus.  Pro- 
jectile vomiting  occurring  early  and  apparently  without  cause  in  an 
otherwise  healthy  appearing  breast-fed  infant,  when  it  can  be  proved 
that  the  mother's  milk  is  without  fault,  should  always  excite  suspicion 
of  this  condition.  There  is  marked  constipation  and  the  lower  abdomen 
is  generally  empty  and  passively  retracted,  while  the  upper  abdomen  is 
bulging  and  tense.  In  cases  in  which  it  is  impossible  to  detect  the  pyloric 
thickening,  even  when  a  whiff  of  chloroform  is  administered,  and  the  bowel 
movements  are  at  times  fecal  and  contain  occasional  curds,  and  there  is 
no  rapid  loss  of  weight  and  strength,  in  spite  of  the  projectile  vomiting 
and  peristaltic  waves,  one  may  probably  assume  the  condition  is  due  to 
pylorospasm.  These  cases,  I  must  say,  are  difficult  to  diagnose,  and  may 
go  on  to  a  slow  recovery  unrecognized,  being  considered  cases  of  difficult 
feeding.  As  an  aid  to  diagnosis,  one  may  say  that,  if  the  infant's  weight 
and  strength  remain  practically  the  same  during  medical  treatment — i.e., 
lavage  twice  daily,  the  temporary  use  of  the  nutritive  enema,  and  later 
careful  mouth-feeding— then  the  assumption  that  the  chief  factor  in  the 
condition  is  due  to  pylorospasm,  either  spastic  or  intermittent,  would  be 
correct  though  Emmet  Holt  believes  there  is  some  fibrous  thickening  even 
in  these  cases,  Hyperchlorhydria  is  believed  to  be  a  factor  in  some 
cases.  Richter^  calls  to  our  attention  that  the  radiograph,  as  a  diagnostic 
measure  should  be  limited  to  determining  the  rate  of  emptying  the  stomach 
and  not  to  the  patency  of  the  pylorus.  One  should  not  exclude  a  diagnosis 
1  Journal,  A.  M.  A.,  Jan.  31,  1914. 


CHRONIC    DILATATION   OF   THE    STOMACH  421 

of  hypertrophic  stenosis  on  the  basis  of  the  fact  that  there  is  some  passage 
of  bismuth  from  the  organ.  He  cites  two  subsequently  fatal  cases  in 
which  this  error  of  interpretation  occurred. 

Treatment. — Dilatation  of  the  pylorus  has  been  suggested  by  Einhorn. 
The  writer  does  not  find  it  practical,  and  in  the  attempt  on  a  young  infant 
one  encounters  insuperable  difficulties.  It  is  important  to  determine 
the  degree  of  pyloric  obstruction  by  measuring  the  amount  of  gastric 
retention.  It  is  best  to  give  for  the  motility  test,  food  that  does  not 
coagulate  such  as  boiled  milk  twice  diluted  with  barley  water  or  barley 
gruel.  Aspirate  three  hours  later  and  measure  the  quantity  and  if  nearly  as 
much  is  obtained  as  previously  ingested  or  if  no  food  has  been  given  during 
the  night  and  in  the  morning  4  to  5  ounces  are  secured  by  aspiration, 
obstruction  is  evident.  If  there  is,  however,  a  progressive  loss  of  weight 
and  strength,  operation  should  not  be  delayed.  Personally,  I  am  very 
skeptical  regarding  the  ultimate  curability  of  congenital  pyloric  stenosis 
by  medical  means,  and  believe  the  so-called  cures  to  be  simply  cases  of 
pylorospasm  which  have  recovered.  I  have  no  faith  in  attributing  dila- 
tation of  the  stomach  in  adults  to  a  congenital  stenosis,  believing  that  a 
careful  investigation  will  show  some  other  cause  for  the  condition. 

Acquired  Stenosis  of  the  Pylorus. — The  usual  symptoms  of  acquired 
stenosis  are  thirst,  dryness  of  the  throat,  dry  skin,  oppression,  feeling  of 
cramp-like  pains  of  considerable  severity,  generally  associated  with 
peristaltic  restlessness  of  the  stomach,  eructation  of  odorous  gas,  vomiting 
of  considerable  chyme,  often  containing  remnants  of  food  taken  the  meal 
or  even  the  day  before.  This  may  occur  from  once  to  several  times 
a  day.  The  bowels  are  extremely  constipated.  Emaciation  may  become 
very  marked  and  the  loss  of  fat  on  the  abdomen  so  great  that  the  skin  is 
in  dry  wrinkled  folds.  The  urine  becomes  markedly  diminished  in 
advanced  cases;  its  reaction  is  frequently  alkaline. 

Intestinal  fermentation  and  putrefaction  with  indicanuria  are  often 
present. 

Bradycardia  and  dyspnea  (cardiac  asthma)  at  times  occur,  as  do  also 
stupor,  headache,  and  so-called  gastric  vertigo. 

Tetany  or  epileptiform  attacks  may  complicate  the  condition. 
The  benign  type  of  stenotic  dilatation  is  characterized  by  rather  a 
long  course,  with  often  considerable  temporary  improvement  under  treatment, 
with  a  tendency  to  relapse. 

In  my  experience  the  cases  of  benign  stenosis  characterized  by  attacks 
of  gastrosuccorrhea  are  more  frequently  associated  with  ulcer  at  the 
pylorus. 

In  the  malignant  type  we  have  the  marked  cachexia  and  rapid  loss  of 
weight  within  a  few  months,  the  age  of  patient  usually  over  forty  or  forty- 
five,  and  the  character  of  the  vomitus  to  be  noted  later.  Secondary 
anemia  is  present  and  tends  to  progress.  There  is  often  moderate  leuko- 
cytosis.    Tumor  is  palpable  later. 

Special  Type. — In  an  interesting  type,  to  which  Robert  T.  Morris  has 
called  attention,  there  may  be  vomiting  of  considerable  blood,  pain,  etc., 
suggestive  of  an  active  ulcer.  Gall-bladder  spider  adhesions  to  the  pylorus 
have  been  found  to  be  the  factor.     The  symptoms  are  probably  explain- 


422  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

able  by  circulatory  interference.  The  history  of  previous  gall-bladder 
disease  should  be  examined  into. 

Examination  of  the  Gastric  Contents  in  Malignant  Pyloric  Stenosis. — 
Cofifee-ground  vomit,  or  the  presence  of  occult  blood;  free  HCl  markedly 
diminished  or  absent,  lactic  acid  present;  few  or  no  sarcince  and  the  Boas- 
Oppler  bacilli  present,  in  connection  with  the  clinical  symptoms,  are 
diagnostic  of  malignant  stenosis.  Meat  is  undigested.  Free  HCl  may 
be  present  even  in  considerable  amount,  especially  in  the  early  stages,  or 
when  the  carcinoma  is  engrafted  on  an  ulcer. 

Gastric  Contents  in  Benign  Stenosis. — With  benign  stenosis  we 
have:  the  gastric  contents  separating  into  three  layers,  the  upper  being 
gaseous;  HCl  is  marked  (hyperacidity);  yeast  and  sarcince  are  abundant; 
undigested  starch  is  present.  Mold  may  be  found  and  occasionally  bile 
or  sulphuretted  hydrogen. 

I  agree  with  Einhorn  that  bile  can  enter  the  stomach  in  some  cases  of 
stenosis  of  the  pylorus,  the  thickened  tissue  allowing  a  slight  patency. 

Diagnosis 

Ectasy  means  dilatation  of  the  stomach  combined  with  motor 
insufficiency. 

We  must,  therefore,  first  determine  the  position  of  the  organ.  Fre- 
quent errors  have  been  made  in  differentiating  dilatation  and  gastroptosis. 
The  position  of  the  upper  border  of  the  stomach  is  the  chief  point. 

There  is  a  simpler  method  which  is  dependent  on  whether  or  not  a 
movable  kidney  be  present.  The  movable  kidney  is  almost  invariably 
part  of  a  general  ptosis  of  the  viscera  (splanchnoptosis),  and  movable 
kidney  from  traumatism  is  extremely  rare. 

If  we  find  a  movable  kidney  with  a  stomach  whose  lower  border  is 
in  an  abnormal  position  (too  low  down),  the  diagnosis  is  gastroptosis. 
If  no  movable  kidney  is  present  and  the  greater  curvature  is  low  down, 
plus  motor  insufficiency  and  symptoms,  the  condition  is  one  of  dilatation. 

An  extremely  simple  method  of  locating  the  lower  border  of  the 
stomach  is  by  the  splashing  sound  (succussion).  This  has  been  fully 
described,  and  also  the  creation  of  the  splash  for  diagnosis.  Dehio's 
method  can  be  used  as  a  check. 

We  may  employ  in  addition: 

1.  Inspection,  which  will  in  some  cases  show  the  outline  of  the  dis- 
tended stomach,  especially  after  distention  with  carbonic  acid  gas.  Active 
peristalsis  is  also  at  times  evident  on  inspection  and  when  present  is  diagnostic 
of  pyloric  obstruction. 

2.  Palpation. — By  this  means  the  peristaltic  movements  may  at  times 
be  felt,  as  can  also  the  cushion-like  resistance  of  the  distended  stomach. 
Occasionally  a  small  oval  tumor  can  be  determined  in  benign  stenosis, 
though  generally  it  is  not  appreciable.  With  carcinoma  of  the  pylorus 
the  hard  resistant  mass  can  often  be  appreciated. 

3.  Percussion  and^  auscultatory  percussion,  especially  before  and  after 
the  addition  of  water,  as  already  described,  are  useful.  The  "scratch 
method  "  is  of  service. 


CHRONIC    DILATATION    OF    THE    STOMACH 


423 


T.\BLE  OF  Differential  Diagnosis 
Atonic  dilatation  Stenotic  dilatation 

Age  All  ages  A .  Benign  stenosis  of    B.  Malignant  stenosis   of 

pylorus,  all  ages  pylorus,  over  40  generally 


Duration. 

Long    unless    re- 

Quite      long,       two 

Short,     few     months    to 

cently  acquired. 

years,         generally 

one       year       or       one 

considerably   more. 

year  and  a  half. 

Course. 

Long,  often. 

Generally     intervals 
of     quiescence     or 
improv  e  m  e  n  t    if 
treated. 

Progressive. 

Tumor. 

None. 

Occasional        (small 

Present;       later       palp- 

and smooth). 

able. 

Pain. 

.\bsent. 

Spasmodic  attacks. 

Always  present  and 
exacerbations. 

Peristaltic     rest- 

None. 

Present,          marked 

Present     and     at     times 

lessness. 

when  advanced. 

marked. 

Vomiting. 

Most    frequently 
absent.   Present 
more    in    hyper- 
acid cases. 

Frequent. 

Fairly  frequent. 

Cachexia. 

None,   but  some 

None,      but      great 

Present. 

loss  of  weight. 

emaciation. 

Symptoms. 

Often        toxemic 

Marked  gastric. 

Marked,   gastric    and 

from    intestinal 

general 

putre  faction, 

referred  to  ner- 

vous        system 

and     not     spe- 

cially     referred 

to  stomach;   at 

times       gastric, 

such        as       of 

chronic  gastritis. 

Blood. 

None  in  vomitus. 

None  except  in  gall- 

Coffee-grounds in  vomit 

bladder      adhesion 

or  occult  blood:  occult 

cases. 

blood  in  stool  or  coffee 
color  blood. 

Gastrosuc- 

Rare. 

More  frequent  with 

Generally  absent,  though 

corrhea. 

ulcer. 

occasional. 

Gastric  Contents 

A  tonic 

dilatation 

Benign  stenosis 

'  Malignant  stenosi 

Total  acidity. 

Lessened;      more 
rarely  increased. 

Increased. 

Generally  diminished. 

tree  hydro- 

Often hypochlor- 

Generally  increased. 

Usually  absent. 

chloric  acid. 

hydria;        more 
rarely        hyper- 
chlorhydria. 

hyperchlorhydria. 

' 

Lactic  acid. 

At  times  present. 

Absent. 

Present,  usually  marked. 

Fermentation. 

Often  marked. 

At  times  marked. 

At  times,  depending  on 
location  of  growth. 

Odor. 

Often  present. 

Unpleasant. 

Fetid  at  times. 

Boas-Oppler   ba- 

Occasional. 

Rare. 

Usually  present. 

cilli. 

Mucus. 

At  times,  if  gas- 
tritis. 

At  times,  if  gastritis. 

In  some  cases. 

Sarcinae. 

Present  often. 

Present  markedly. 

Usually  absent. 

Yeast. 

Marked  at  times. 

Often  present. 

Pronounced  yeast  fer- 
mentation rare. 

424  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

4.  Inflation. — The  stomach  may  be  inflated  with  air  or  carbonic  acid 
gas.  The  outlines  can  thus  be  more  readily  determined  and  the  position 
of  the  upper  curvature  mapped  out.  Inflation  with  air  or  water  renders 
a  tumor,  if  present,  more  evident  to  percussion  and  palpation  if  it  lie  on 
the  anterior  wall.     It  disappears  if  posterior. 

5.  Transillumination. — This  method,  especially  with  the  circum- 
scribing gastrodiaphane  and  fluorescein,  readily  determines  the  outline 
of  the  stomach  and  differentiates  between  dilatation  and  gastroptosis 
in  disputed  cases.  It  is  often  unnecessary.  The  use  of  mensuration  by 
means  of  stiff  sounds  is  deprecated. 

X-rays. — The  x-rays  are  of  particular  value  in  cases  of  stenotic  dila- 
tation of  the  stomach,  determining  changes  in  the  contour  of  the  organ, 
distortions,  etc.,  suggesting  ulcer,  carcinoma  or  other  causes.  The 
residue  of  bismuth  six  hours  after  the  meal  also  gives  an  index  as  to 
motility — ^though  the  writer  beUeves  the  test-meal  is  more  accurate  as 
regards  to  qualitative  motility  tests.  For  example,  minor  degrees  of  motor 
insufficiency  will  show  after  the  test  breakfast  or  test  meal,  while  the 
stomach  in  the  radiograph,  at  the  end  of  six  hours  after  the  barium  meal, 
may  be  empty.  The  radiologist  may  state  motility  is  good,  on  the  basis 
of  the  six-hour  radiograph,  while  actually  some  lesser  degree  of  motor 
insufficiency  may  exist.  This  fact  is  of  special  importance,  as  otherwise 
we  might  fail  to  properly  treat  a  case  of  minor  degree  of  atonic  dilatation 
of  the  stomach.  I  have  seen  such  occur.  The  atonic  cases  of  gastric 
dilatation  when  determined  by  the  r»;-ray,  show  a  contour  perfectly  even 
(no  distortion)  and  there  is  evidence  of  some  immediate  escape  of  bismuth, 
with  an  open  pylorus  {i.e.,  compensatory  relaxation),  though  there  may 
be  some  retention  at  the  end  of  six  hours  in  the  more  marked  cases.  The 
a;-rays  are  not  absolutely  necessary  for  diagnosis  of  the  atonic  type  of 
dilatation,  though  a  wise  precaution  to  avoid  possible  error. 

Motor  Functions. — The  determination  of  the  motor  functions  is  most 
important,  as  motor  insufficiency  is  a  salient  feature.  There  are  different 
degrees  of  this  motor  insufficiency,  and  this  is  best  determined  by  the 
test-breakfast  or  test-meal  as  noted  above. 

Test-breakfast. — Ewald's  test-breakfast.  Aspirate  the  contents  one 
hour  later. 

1.  Normal  position  of  the  stomach,  with  a  residuum  aspirated  of  100 
c.c.  or  over,  and  symptoms,  show  atony  of  the  stomach. 

2.  Descent  of  the  lower  border  of  the  stomach;  100  to  150  to  200  c.c. 
residuum  or  more,  with  symptoms,  and  with  kidneys  in  normal  position 
show  dilatation  of  the  stomach. 

3.  If  movable  kidney,  gastroptosis  is  present. 

Six  or  seven  hours  after  Leube's  test-meal  the  healthy  stomach  should 
be  found  empty.  If  undigested  food  is  found  (300  to  600  c.c.  or  more), 
insufficiency  is  present  and  the  degree  of  insufficiency  is  indicated  by  the 
amount  of  residuum. 

It  is  always  preferable  to  wash  the  stomach  before  the  test-meal,  so 
as  to  get  rid  of  the  old  residuum  and  make  an  accurate  test.  If  consider- 
able residuum  be  found  at  the  end  of  seven  hours,  a  further  test  should 
be  made.     Wash  the  stomach  and  directly  thereafter  give  at  10  p.  m.  a 


CHRONIC    DILATATION    OF    THE    STOMACH  425 

light  supper — a  little  soup,  a  slice  of  bread,  a  slice  of  beef,  and  a  little 
chopped  spinach  with  a  small  amount  of  boiled  rice  and  a  dozen  raisins 
without  seeds.  Aspirate  and  measure  residuum  and  wash  the  stomach 
twelve  hours  later  before  breakfast,  noting  if  additional  material  in  wash 
water.  In  some  cases  there  will  be  a  marked  residuum  after  seven  hours, 
hut  none  after  twelve  hours;  in  others  there  will  also  be  considerable  after 
twelve  hours,  showing  different  degrees  of  insufficiency. 

The  stomach  should  be  washed,  as  well  as  aspirated,  to  remove  all 
the  contents.     Also  aspirate  the  empty  stomach  to  test  for  hypersecretion. 

The  salol  and  olive  oil  tests  are  not  as  reliable. 

Treatment 

The  treatment  of  chronic  dilatation  of  the  stomach  varies  consider- 
ably, depending  on  whether  it  be  due  to  atony  or  to  benign  or  malignant 
stenosis.     Cases  due  to  stenosis  whether  benign  or  malignant  are  surgical. 

Atonic  Dilatation. — This  is  by  far  the  most  frequent  type  of  dilatation 
which  we  are  called  upon  to  treat,  especially  among  bankers,  brokers, 
and  professional  men,  who  habitually  overeat,  bolt  their  food,  or  are 
heavy  drinkers.  Associated  with  or  having  a  direct  bearing  on  this 
condition,  we  may  find  hypochlorhydria,  hyperchlorhydria,  or,  at  times, 
chronic  gastritis.  Some  of  these  cases  are,  in  their  incipiency,  of  rather 
mild  type,  and  prophylaxis,  as  regards  avoiding  rapidity  of  eating  and 
eliminating  indigestible  food  and  overeating,  is  of  value.  If  the  patient 
is  run  down  or  anemic,  iron  and  tonic  treatment  are  indicated. 

Diet. — Though  some  have  recommended  a  so-called  dry  diet  in 
dilatation  of  the  stomach,  it  is  a  well-known  fact  that  liquids  are  first 
evacuated  from  the  stomach,  then  mushy  food,  and  finally  solid  food, 
and  this  scientific  knowledge  should  be  our  guide  in  feeding  such  cases. 
Water  and  food  soluble  in  water  leave  the  stomach  soonest  of  all. 

Large  quantities  of  fluid  should  not  be  given  at  a  time  lest  they  over- 
distend  the  flaccid  stomach,  but  if  they  are  administered  in  smaller 
quantities  at  frequent  intervals,  a  considerable  amount  can  be  employed. 

It  has  been  demonstrated  that  alcohol,  sugar,  and  dextrin  cause  a 
secretion  of  water  in  the  stomach. 

Milk  has  been  usually  recommended  as  the  standard  diet  in  this  con- 
dition as  possessing  highly  nutritive  properties,  and  the  statement  has 
been  made  that  it  does  not  stay  in  the  stomach  much  longer  than  plain 
water. 

Penzoldt  has  demonstrated  that  water,  cocoa,  meat  broth,  soft- 
boiled  eggs,  and  boiled  milk  (100  to  200  gm.)  leave  the  healthy  stomach 
within  one  to  two  hours,  cooking  altering  the  curd  formation. 

Raw  milk  takes  a  considerably  longer  period,  and  curds  have  been 
found  frequently  in  the  normal  stomach  two  or  three  hours  after  ingestion. 

Experiments  have  been  conducted  on  my  service  at  the  Manhattan 
State  Hospital  in  cases  of  dUatation  of  the  stomach,  and  the  periods  for 
the  raw  milk  to  remain  in  the  stomach  were  investigated.  After  three 
hours  large  masses  of  curd  were  aspirated. 

If  the  milk  were  diluted  one-half  with  water,  the  residuum  found  at  a 
certain  period  was  just  one-half  as  much  as  when  pure  raw  milk  was  used, 


426  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

which  formed  curds.  The  higher  the  dilution,  the  greater  the  quantity- 
passed  from  the  dilated  stomach  within  a  definite  time.  Another  objec- 
tion is  that  I  liter  of  milk  only  represents  about  640  calories,  and  too  large 
an  amount  would  be  required  if  sufiicient  nutrition  is  to  be  obtained  from 
milk  alone.  Strained  soups  and  strained  gruels  are  evacuated  more 
rapidly.  If  milk  be  given,  it  should,  preferably,  be  combined  with  some 
strained  gruel  or  the  latter  made  with  milk,  so  that  the  nutritive  value 
may  be  increased. 

In  the  severer  type  of  cases  the  diet  suggested  by  Seibert  in  typhoid 
appeals  strongly  to  the  author.  It  possesses  considerable  nutritive  value, 
namely : 

Strained  rice,  8  ounces  (250  c.c),  barley  or  oatmeal  soup  containing 
the  extract  of  >^  pound  of  meat  and  the  yolk  of  a  fresh  egg.  This  can  be 
spiced  slightly  to  improve  the  flavor,  except  in  hyperacid  cases.  It  can 
be  given  five  or  six  times  daily. 

Strained  pea  soup,  lentil,  tomato,  or  potato  soup  can  be  used  in 
addition. 

Rice  flour  is  excellent  in  the  form  of  a  thin  gruel,  and  can  be  made 
with  milk  which  has  been  thoroughly  boiled.  The  object  should  be  to 
give  frequent  (five  or  six  smaller)  meals,  so  as  not  to  overburden  the 
stomach,  and  yet  secure  a  sufficient  amount  of  nutrition  to  improve  the 
patient's  physical  condition. 

Cream,  2  ounces  (60.0)  in  4  ounces  (125  c.c.)  of  water,  possesses 
considerable  nutritive  value.     I  have  given  as  much  as  half  a  pint  daily. 

Crackers  heated  thoroughly  and  well  buttered  can  be  rubbed  up  in 
the  broth. 

Fat  in  the  form  of  cream  and  butter  up  to  >^  to  3-2  pound  daily 
should  be  administered. 

In  the  milder  cases,  scraped  beef,  rare  beef,  soft-boiled  eggs  thickened 
with  a  small  amount  of  mashed  potatoes,  and  rice  strained  through  a 
colander,  with  plenty  of  butter,  can  be  given,  with  a  little  asparagus  and 
spinach.     Other  vegetables  are  more  difficult  to  expel  from  the  stomach. 

Matzoon,  koumiss,  bacillac,^  kefir,  and  milk  prepared  with  lactone 
tablets  (lactone-buttermilk)  are  of  special  value  in  cases  suffering  from  auto- 
intoxication, having  nervous  symptorns  and  indicanuria  (intestinal  putre- 
faction). The  matzoon  can  be  diluted  with  one- third  water  or  Vichy  that 
has  been  allowed  to  become  flat.  This  last  avoids  gaseous  distention  of 
the  atonic  stomach.  It  is  also  preferable  to  allow  some  of  the  gas  to  pass 
off  from  the  koumiss.  About  i  quart  of  one  of  these  preparations  can 
be  used  daily — additional  water  or  Vichy  one-third  in  volume  being  then 
added.  These  sour  milk  preparations,  especially  with  the  slight  dilution, 
pass  readily  from  the  stomach.  They  do  not  curdle  like  plain  milk.  The 
yolks  of  several  raw  eggs,  stale  bread  or  crackers  with  plenty  of  butter 
and  cream,  strained  vegetable  soups,  and  rice  gruel,  can  be  added.  Meat 
preparations  should  be  avoided  in  these  cases. 

In  cases  with  deficiency  of  hydrochloric  acid,  the  meats  are  not  well 
digested  and  should  be  given  in  smaller  quantities;  rice,  barley,  and 
tapioca  (strained)  or  in  purees,  and  mashed  potatoes  are  of  service,  and 
1  Fermillac  also  is  of  value. 


CHRONIC    DILATATION    OF    THE    STOMACH 


427 


in  larger  amounts.  I  have  often  found  raw  eggs  beaten  up  in  water  or 
milk  of  great  service,  employing  at  times  six  to  eight  daily.  The  milk 
can  be  completely  or  partially  peptonized  to  lessen  curd  formation.  With 
the  precaution  noted,  milk  may  be  employed  in  the  cases  with  not  too 
marked  motor  insufficiency.  It  is  a  simple  matter  to  test  whether  it 
leaves  the  stomach  readily  or  not. 

If  thirst  is  marked,  rectal  enemata  of  hot  normal  saline  solution  are 
indicated,  and  in  very  severe  cases  the  stomach  may  be  given  a  rest  and 
nutritive  enemata  be  given  for  a  few  days.  Proctoclysis  is  of  value  for 
the  thirst,  or  hypodermoclysis  in  severe  cases. 


Fig.  212.  Fig.  213. 

Fig.  212. — Dilatation  of  the  stomach.  Transillumination  with  fluorescein  before 
application  of  Rose's  belt  (Case  i)  (Ward's  Island  Gastro-intestinal  Clinic,  Manhattan 
State  Hospital). 

Fig.  213. — Dilatation  of  the  stomach,  same  patient  (Case  i).  Transillumination 
with  fluorescein  after  application  of  Rose's  belt.  By  accurate  measurement  the  stom- 
ach has  been  elevated  and  the  lower  border  is  4  inches  higher  than  it  was  before  the 
belt  was  applied.  The  lower  border  now  lies  above  the  umbilicus  (Ward's  Island 
Gastro-intestinal  Clinic,  Manhattan  State  Hospital). 


Tropon,  and  somatose  are  useful  adjuncts,  given  in  divided  doses  in 
the  broths.  If  anemia  is  present,  iron  tropon  can  be  added,  i  dram 
(4.0),  three  times  a  day  or  any  good  iron  preparation,  particularly  com- 
bined with  arsenic.     Always  peptonize  the  milk  if  given  by  enema. 

After  eating,  the  patient  should  lie  down  for  from  one-half  an  hour 
to  an  hour,  preferably  on  the  right  side,  so  the  stomach  can  empty  itself 
more  readily. 

Mechanic  Support. — One  of  the  most  important  methods  of  treatment 
is  the  use  of  proper  support  to  the  organ,  and  the  ideal  method  is  by 


428  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Rose's  adhesive  plaster  belt,  a  description  of  which  has  been  given.  It 
increases  intra-abdominal  pressure  and  the  stomach  is  pushed  upward, 
acting  in  effect  like  gastro plication.  Transillumination  was  employed  in 
one  case  (Fig.  212),  the  belt  applied,  and  transillumination  again  carried 
out  (Fig.  213). 

The  illustration  (Fig.  213)  shows  the  result,  the  lower  border  of  the 
stomach  being  elevated  4  inches.  Though  Pancoast,  Sailer,  and  Worden^ 
claim  that  the  x-ray  has  determined  that  no  form  of  belt,  binder,  or 
corset  elevates  the  stomach  to  the  smallest  extent,  in  the  experiments 
described  after  illumination  of  the  stomach  without  support,  the  patient 
was  then  placed  in  the  Trendelenburg  position,  and  Rose's  belt  applied. 
It  was  clearly  demonstrated  the  elevation  had  then  occurred.  The 
same  excellent  result  can  be  demonstrated  by  radiography  before  and 
after  Rose's  belt  is  applied.  Some  of  the  properly  made  corsets  will  also 
elevate  the  stomach  as  is  demonstrated  by  radiographs  in  this  volume. 
This  belt  should  be  worn  four  or  five  weeks  and  a  new  one  then  applied. 
It  aids  in  the  evacuation  of  the  stomach  contents.  Silk  abdominal  belts 
may  be  substituted,  but  the  support  is  not  continuous  and  the  adhesive 
strapping  is  superior.  From  the  positive  results  secured  by  the  writer, 
he  can  only  assume  that  if  adhesive  strapping  was  employed,  the  technic 
was  not  correct  in  Pancoast's  cases.  Undoubtedly  many  of  the  belts 
and  corsets  are  useless. 

General  Hydrotherapy. — External  douches — the  fan  douche  and 
also  the  Scotch  douche  applied  to  the  region  of  the  stomach  and  changing 
the  temperature  of  the  water — have  been  serviceable  in  some  cases.  Cold 
compresses  and  cold  sponging  are  at  times  useful.  An  adjustable  silk 
belt  is  worn  in  such  events. 

Local  Treatment  of  the  Stomach. — (i)  Lavage. — In  some  of  the  milder 
atonic  cases  proper  diet,  mechanical  support,  and  appropriate  medication 
may  suffice  without  or  with  occasional  lavage.  In  the  more  severe  cases 
lavage  is  indicated,  and  the  time  of  its  performance  and  frequency  de- 
pend upon  the  degree  of  dilatation  and  the  amount  of  residuum  found 
after  the  test-meal  (degree  of  motor  insufficiency).  If  there  is  not 
immediate  improvement  if  lavage  is  omitted,  it  must  be  added  to  the 
treatment. 

If  a  large  amount  of  residuum  is  present  after  a  test-meal  or  test- 
breakfast,  or  there  are  nervous  symptoms,  or  in  the  morning  before 
breakfast  a  residuum  is  present,  lavage  should  be  carried  out. 

As  to  the  proper  hour  for  lavage,  I  believe  Riegel  holds  sound  views, 
and  my  own  experience  agrees  with  his;  if  the  residuum  is  200  to  500  c.c. 
or  more  before  supper,  it  is  best  to  wash  the  stomach  then  and  follow 
with  a  hght  meal;  if  this  is  not  done,  the  organ  will  contain  fermenting 
food  during  the  night  which  will  increase  the  atony.  If  food  is  present 
before  breakfast  a  second  lavage  is  then  indicated. 

The  washing  should  be  performed  with  the  patient  both  sitting  and 
lying  down,  turning  on  each  side  particularly  on  the  right,  so  as  to  remove 
all  the  irritating  material.  The  stomach  should  be  washed  until  the  return 
is  clear. 

*  Trans.  Coll.  Phys.,  Philadelphia,  1906,  series  3,  xxviii,  1 51-196. 


CHRONIC    DILATATION    OF    THE    STOMACH  429 

Daily  lavage  is  generally  necessary  at  first.  As  the  tone  of  the  stomach 
improves,  the  residuum  found  will  decrease  and  washing  may  be  per- 
formed less  often.  The  first  part  of  the  washing  may  be  done  with 
plain  warm  water,  though  normal  saline  solution  is  preferable. 

I  have  found  milk  of  magnesia  (Phillips),  2  ounces  (60.0)  to  i  quart 
(liter)  of  water,  excellent  for  the  preliminary  lavage.  It  is  well  to  employ 
antifermentatives  in  the  final  treatment,  such  as — 

Acid  salicylic i  :  1000 

Sodium  salicylate i  :  1000 

Sodium  benzoate i  :  1000 

Listerin \ 

Glycothymolin i  3j  (4-0)  to  i  quart  (liter). 

Borolyptol J 

Resorcin  or 1  gr.  15  to  30  (1.0-2.0)   to   i 

Boric  acid /      quart  (liter). 

(2)  Electricity. — The  intragastric  faradic  current  (preferably)  can  be 
employed  if  there  be  no  objection  on  the  part  of  the  patient,  using  Lock- 
wood's  instrument.     In  many  cases  the  percutaneous  method  is  advisable. 

Static  electricity  is  claimed  to  be  of  value,  and  in  some  cases  to  reduce 
the  size  of  the  atonic  dilated  stomach. 

Massage  or  vibratory  massage  is  of  service  to  tone  the  musculature  and 
aid  in  emptying  the  stomach. 

(3)  The  stomach  douche  has  been  recommended  in  the  milder  forms 
to  stimulate  the  organ.  The  fluid  should  be  at  a  temperature  of  95°  to 
85°F.  (gradually  reduced). 

If  hydrochloric  acid  is  diminished,  normal  salt  solution  may  be  em- 
ployed; if  HCl  is  increased,  then  use  silver  nitrate  i  :  3000  to  i  :  2000,  or 
protargol  or  argyrol  i  :  2000. 

Bitter  remedies,  such  as  quassia  (fluidextract) ,  15  minims  to  }4  dram 
(0-888-1.77  c.c),  or  a  cup  of  quassia-water  (quassia  cup  filled  with  water 
and  allowed  to  set  for  half  an  hour);  or  hops  (fluidextract  lupulin),  15 
minims  to  }^  dram  (0.888-1.77  c.c),  or  fluidextract  of  condurango,  J.^ 
to  I  dram  (1.77-3.54  c.c.)  to  a  liter  of  water,  have  been  recommended  for 
lavage  as  a  stimulant,  but  I  see  no  special  value  in  their  use. 

The  stomach  spray  has  also  been  suggested  in  place  of  the  stomach 
douche,  but  it  possesses  the  disadvantage  of  injecting  considerable  air. 

Medicines. — If  there  is  deficiency  of  hydrochloric  acid,  the  stomachics 
and  hydrochloric  acid  should  be  administered,  such  as  are  employed  in 
chronic  gastritis.     The  following  prescription  is  often  valuable: 

I^.  Tinct.  nucis  vomicae  ^  r■'•••^ 

Acid  hydrochloric,  dilute  / ^*     "•°  '■^"J^' 

Comp.  tinct.  cinchona 16.0  (5ss); 

Aq.  destil q.  s.  ad.  125.0  (3iv). — M. 

Sig. — One  to  two  teaspoonfuls  in  a  wineglassful  of  water  t.i.d.  half  an 
hour  before  meals. 

Oxyntin  with  nux  vomica,  one  to  two  capsules  t.i.d.,  before  or  after 
meals,  is  useful. 

If  there  is  hyperacidity,  magnesia  usta,  15  grains  to  >^  dram  (i.o- 
2.0)  or  more,  in  water  t.i.d.  an  hour  after  meals.  Or  milk  of  magnesia 
(Phillips),  I  to  2  drams  (4.0-8.0),  in  water.     These  are  excellent  remedies. 


430  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

If  bicarbonate  of  soda  be  employed,  it  is  better  to  combine  it  with 
magnesia  usta,  equal  parts,  as  it  readily  generates  carbonic  acid  gas. 

In  the  atonic  type  of  dilatation  I  have  always  been  inclined  to  employ 
nux  vomica  or  its  alkaloid  as  a  stimulant  to  the  musculature  of  the 
stomach,  even  though  hyperacidity  be  present,  which  is  rare;  in  the 
latter  event  combining  belladonna  with  the  nux,  as  a  pill,  before  meals: 


R.  Ext.  nucis  vomicae  \  --  >/  /        <:\ 

Tr„.   u„ii„j r aa   gr.  k  (0.016). 


-M. 


Ext.  belladonna       / 
or 

I^.  Strychnin gr.  Ho  (0.00108); 

Atropin. gr  Moo  (0.00064). — M. 

If  nux  vomica  is  incorporated  in  the  stomachic  mixture,  it  should 
not  be  repeated.  If  the  tincture  of  nux  vomica  is  employed,  it  can  be 
gradually  increased  to  large  dose — }4  dram  (2.0)  t.i.d. 

For  fermentation  and  intestinal  putrefaction  the  following  remedies 
are  of  service,  given  three  times  a  day  half  an  hour  to  an  hour  after 
meals:  Salicylate  of  soda,  benzoate  of  soda,  ichthoform,  ichthalbin, 
bismuth  salicylate,  salol,  resorcin,  benzonaphthol,  bismuth  phenolate, 
or  bismuth  sulphocarbolate,  all  in  doses  of  5  grains  (0.3)  each.  Hexa- 
methyl-enamin  5  grains  (0.3),  given  in  combination  with  sodium  benzoate, 
5  grains  (0.3),  in  water  t.i.d.  after  meals,  is  also  useful. 

I  have  found  resorcin  an  excellent  remedy,  alone  or  combined  with 
bismuth  subnitrate.  If  mold  is  present  the  creosote  preparations  are 
preferable,  such  as  beech  wood  creosote,  i  minim  (0.059  c.c),  or  carbonate 
of  creosote  (creosotal),  5  grains  (0.3),  three  times  a  day  after  meals. 

For  constipation  the  olive  oil  injections  at  night,  to  be  retained,  4 
ounces  to  i  pint  (125-500  c.c.)  or  more;  massage,  electricity,  the  establish- 
ment of  a  regular  hour  for  stool,  the  administration  of  a  glass  of  water  on 
rising,  and,  if  required,  the  use  of  the  cascara  preparations  or  the  aloin  and 
belladonna  pill,  regulin,  or  one  of  the  phenolphthalein  preparations,  such 
as  phenolax  or  purgen,  at  night.  Russian  mineral  oil  §  ss  A.  m.  and  p.  m. 
or  American  mineral  oil,  vaselin  5i~3ii  t.i.d.  or  albolene,  5ss  A.  m.  and 
p.  M.  or  olive  oil  3ii-5ss-5i  t.i.d.  are  excellent.  The  saline  cathartics  are 
objectionable. 

Gastrosuccorrhea  is  rare  in  the  atonic  type  of  dilatation.  In  the 
event  of  its  presence,  lavage  with  nitrate  of  silver  (i  :  2000)  twice  a  week, 
and  belladonna  tincture,  10  minims  (0.592  c.c.)  t.i.d.,  or  extract  of 
belladonna,  J-^  grain  (0.022)  t.i.d.  or  atropine  gr.  Hoo~3^o  t.i.d.  are 
indicated.  For  further  treatment,  the  chapter  on  this  subject  should 
be  consulted. 

For  gastric  tetany,  which  may  occur  in  the  atonic  type  of  ectasy,  but 
which  is  a  rare  condition,  lavage  is  of  service,  but  gastro-enterostomy  is 
indicated.  Moynihan  has  operated  on  14  cases  of  gastric  tetany,  with 
cures  in  all. 

Surgery. — In  atonic  ectasy,  when  no  improvement  occurs  under  treat- 
ment or  when  the  dilatation  is  of  great  degree  and  the  patient's  condition 
seems  to  be  getting  worse,  operation  is  indicated — preferably  drainage  of 
the  stomach  by  gastro-enterostomy. 


CHRONIC    DILATATION    OF    THE    STOMACH  43 1 

Gastroplication — infolding  the  wall  of  the  stomach  and  sewing  it  in 
pleats — has  also  been  successfully  reported.  CofTey  has  sutured  the 
greater  omentum  to  the  abdominal  wall  and  thus  supported  the  stomach 
in  a  hammock.     He  reports  two  favorable  results. 

TREATMENT  OF  STENOTIC  DILATATION  (BENIGN  STENOSIS) 

The  author  wishes  to  preface  this  section  with  the  statement  that 
he  considers  all  cases  of  pyloric  stenosis  to  belong  to  the  surgeon.  He  does 
not  consider  them  curable  except  by  radical  operation.  Moreover  carcinoma 
may  form  on  the  cicatrix.  The  medical  treatment  is  only  palliative; 
though  some  cases  may  live  many  years,  especially  the  milder  types,  but 
always  be  under  the  care  of  a  physician  for  a  considerable  period  during 
each  year.  In  addition,  some  cases  when  untreated  may  become  so  re- 
duced as  to  be  unfit  for  operation.  Medical  treatment,  lavage,  often 
twice  daily,  accompanied  by  proper  methods  of  feeding  by  mouth,  to- 
gether with  nutritive  enemata,  may  so  improve  the  physical  condition  of 
these  patients  that  they  can  in  a  short  time  undergo  operation.  This  was 
particularly  demonstrated  in  a  case  of  carcinomatous  stenosis  in  which 
the  methods  of  feeding  are  described  under  Carcinoma  of  the  Stomach. 

Treatment  of  Congenital  Stenosis  of  the  Pylorus. — This  is  surgical — 
gastro-enterostomy  as  early  as  the  positive  diagnosis  can  be  made.  In 
the  cases  with  hyperacidity  which  are  more  intermittent  in  character, 
and  which,  under  medical  treatment,  retain  their  weight  and  strength — 
the  condition  may  be  believed  to  be  due  to  pylorospasmus.  The  ic-rays 
are  of  value  in  determining  the  character  of  the  stenosis.  If  the  condition 
is  spasmodic — correction  of  acidity  before  the  second  radiograph  and 
previous  to  the  a;-rays  the  administration  of  belladonna — 3  to  5  drops  will 
diminish  spasm  and  the  previous  large  amount  of  retained  bismuth  may 
not  appear.  The  medical  treatment  consists  of  lavage  twice  daily  with 
a  warm  weak  solution  of  soda  bicarbonate,  i  to  2  drams  (4.0-8.0)  to  the 
pint  500  c.c),  proper  feeding  by  mouth,  nutritive  enemata,  and  small 
doses  of  strontium  bromid,  3  to  5  grains  (0.2-0.3),  ^Y  rnouth  or  rectum. 
Correct  hyperchlorhydria  if  present.  This  method  can  be  tried  for  a 
short  time  in  any  event,  and  if  the  symptoms  continue  and  the  loss  of 
weight  and  strength  are  progressive,  one  may  assume  the  case  to  be  due 
to  stenosis,  in  which  event  operation  is  indicated  gastro-enterostomy. 
Incision  through  the  indurated  tissue  down  to  the  mucosa  has  been 
employed.  This  method  is  rapid  and  produces  little  shock.  Einhorn^ 
advocates  the  use  of  an  infantile  pyloric  dilating  catheter,  but  the  writer 
does  not  advise  his  method. 

Medical  Treatment  of  Acquired  Stenosis  of  the  Pylorus. — This  is  only 
justifiable  when  the  patient  refuses  surgery  or  to  prepare  for  operation. 
In  early  stenosis  of  the  pylorus  due  to  syphilis,  I  have  seen  a  few  cases 
relieved  apparently  by  antisyphilitic  treatment  without  surgery.  On 
the  other  hand,  cases  mith  marked  symptoms  of  stenosis  in  my  experience 
have  always  ultimately  required  gastroenterostomy  in  addition  to  the 
treatment  for  lues.  In  the  cases  of  acquired  stenosis  where  there  is  a 
mechanical  obstruction  to  the  exit  of  the  gastric  contents,  the  muscular 

^  Med.  Rec,  June  10,  191 1. 


432  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

action  is  increased  during  the  earlier  stages  and  hypertrophy  of  the 
pyloric  end  of  the  stomach  is  present;  later  the  fundus  and  body  become 
distended  and  thinner.  Gentle  massage  from  left  to  right,  or  vibratory 
massage  by  the  same  method,  the  patient  lying  on  the  right  side  and  the 
manipulations  being  performed  an  hour  or  two  after  meals,  may  aid  in 
emptying  of  the  stomach.  Electricity  is  of  slight  or  no  value.  I  have 
seen  no  permanent  benefit  from  these  methods  in  the  obstructive  type  of 
dilatation.  Olive  oil,  2  to  4  ounces  (60.0-125.0  c.c),  administered  three 
or  four  times  a  day  before  meals  will  aid  the  passage  of  the  food  through 
the  stenosed  region,  and  Rose's  adhesive  plaster  belt  is  also  of  service  to 
elevate  the  stomach,  and  render  its  emptying  more  easy. 

The  diet  must  be  liquid  in  the  worst  cases  and  mushes  may  be  em- 
ployed in  the  less  severe  types.  Raw  eggs,  six  to  eight  a  day,  plenty  of 
fat,  such  as  butter  and  cream,  somatose,  and  tropon,  are  all  of  service. 
The  general  method  of  feeding  with  small  frequent  meals  is  the  same 
as  in  atonic  ectasy.  Improvement  in  weight  must  be  secured.  Solid 
food  is  objectionable.  "The  sour  milks,  such  as  bacillac,  lactone- 
buttermilk,  kefir,  matzoon,  and  koumiss,  administered  after  the  manner 
described  in  Atonic  Ectasy,  are  of  value."  The  patient  should  lie  on  the 
right  side  for  about  half  an  hour  after  each  feeding  in  order  to  facilitate 
the  exit  of  the  food  from  the  stomach.  Lavage  is  always  necessary,  and 
for  the  attacks  of  spasmodic  pain  is  the  most  rapid  method  to  secure 
relief.  As  hyperacidity  is  present,  alkalis  are  indicated  to  correct  this 
condition,  as  in  hyperchlorhydria.  The  writer  has  referred  to  a  case  of 
carcinoma  of  the  stomach  upon  whom  the  surgeons  would  not  operate 
on  account  of  his  weakened  physical  condition.  This  patient  was  prepared 
for  subsequent  operation  by  the  above  methods. 

Tincture  of  belladonna  in  large  doses,  10  to  15  drops  t.i.d.  or  atropin 
gr.  Hoo~Hoj  will  often  relieve  spasm  and  pain,  as  will  also  the  application 
of  heat. 

Vomiting. — For  vomiting  lavage  is  indicated,  followed  for  several 
days  by  rectal  feeding,  and  then  commencing  with  a  small  amount  of 
liquid  nourishment. 

Rectal  injections  of  normal  saline  solution,  8  ounces  to  i  pint  (250- 
500  c.c),  may  be  indicated  to  relieve  thirst  and  collapse.  Proctoclysis 
is  of  service. 

Thiosinamin,  5  grains  (0.3)  t.i.d.  by  mouth,  or  3-grain  (0.2)  doses  in 
15  per  cent,  alcoholic  or  10  per  cent,  glycerinated  solution  by  hypodermic, 
have  been  reported  to  be  of  service  in  fibrous  contractures  of  the  pylorus. 
Fibrolysin  (thiosinamin  and  sodium  salicylate,  Merck),  each  ampoule 
containing  0.2  gram  thiosinamin,  can  be  given  daily  or  every  other  day, 
for  a  month  or  two,  in  cases  refusing  operation.  The  writer  has  not  been 
successful  with  this  method,  though  it  should  be  tried  in  cases  refusing 
operation. 

Gastrosuccorrhea  may  occur  in  cases  when  there  is  an  ulcer  with 
stenosis  at  the  pylorus  and,  rarely,  hemorrhages.  Temporary  treatment 
as  for  hemorrhage  of  gastric  ulcer  is  indicated,  and  then  surgical  procedure. 
The  trieatment  for  gastrosuccorrhea,  is  described  in  the  chapter  on  that 
subject. 


COMPLICATIONS    OF    CHRONIC   ECTASY  433 

Gastric  tetany  may  be  a  complication  for  which  lavage  is  indicated 
temporarily,  and  then  operation  (gastro-enterostomy). 

I  have  seen  cases  of  ectasy  from  benign  stenosis  lose  75  pounds  in 
weight  and  regain  50  to  60  pounds  under  treatment,  and  ultimately 
relapse  and  come  to  operation.  I  have  treated  many  patients  of  this  type, 
so-called  brilliant  cures  by  specialists,  the  ultimate  results  being  the  same. 
They,  even  at  the  best,  tend  to  become  chronic  invalids  and  always 
require  treatment.     The  best  physician  for  these  cases  is  the  surgeon. 

If  the  cause  of  the  stenosis  lies  external  to  the  pylorus,  bands,  ad- 
hesions, etc.,  can  be  separated.  If  it  is  intrinsic,  resection  of  the  pylorus, 
pyloroplasty,  or  gastroduodenoplasty  can  be  performed  in  suitable  cases, 
or  drainage  by  gastro-enterostomy.  The  latter  is  usually  the  operation 
of  selection.     Divulsion  I  do  not  approve. 

I  have  seen  a  patient  gain  100  pounds  in  weight  in  eight  weeks  after 
gastro-enterostomy,  and,  from  being  a  confirmed  invalid,  restored  to 
perfect  health.  Einhorn^  advocates  the  use  of  his  dilating  catheter  or 
pyloric  dilator  with  diaphane  to  stretch  the  stenosed  pylorus.  The  writer 
knows  the  method  to  be  uncertain,  and  the  results  not  permanent. 
Valuable  time  is  thus  lost.    Surgery  is  always  indicated  for  stenosis. 

Malignant  Stenosis 

In  these  cases  early  radical  operation  is  indicated,  as  described  under 
Cancer  of  the  Stomach;  otherwise,  palliative  gastro-enterostomy  or  gas- 
trostomy if  stenosis  at  the  cardia.  If  operative  procedure  be  refused, 
then  diet,  lavage,  and  the  treatment  laid  down  under  Carcinoma  Ventriculi. 

COMPLICATIONS  OF  CHRONIC  ECTASY 
Gastric  Tetany 

Tetany  is  characterized  by  peculiar  bilateral  tonic  spasm  of  the 
extremities,  either  paroxysmal  or  continued. 

Pathology. — In  all  cases  there  is  dilatation  of  the  stomach  of  a  high 
degree,  due  generally  to  stenosis  of  the  pylorus  or  the  duodenum;  fre- 
quently the  result  of  an  ulcer;  rarely  from  carcinoma. 

Gastrosuccorrhea  has  been  associated  with  it  in  some  cases.  Tetany 
has  also  been  reported  with  acute  ectasy  and  in  atonic  ectasia. 

Etiology. — There  are  three  theories  as  to  its  cause: 

(i)  Kussmaul  and,  later,  Fleiner  believed  its  symptoms  are  due  to 
the  great  loss  of  fluid  in  the  system,  the  thickening  of  the  blood,  and  the 
consequent  drying  of  the  tissues. 

(2)  Friederick  Miiller  and  Germain  See  consider  it  to  be  the  result  of 
some  reflex  action,  as  Miiller  brought  on  an  attack  by  tapping  the  epi- 
gastric region.  Riegel  has  observed  it  on  passing  the  stomach-tube;  and 
it  has  also  occurred  in  cases  of  intestinal  worms. 

(3)  The  third  theory  explains  it  on  the  ground  of  auto-intoxication, 
since  fermentation  and  putrefaction  are  present  in  the  stomach. 

This  last  is  probably  correct,  as  the  cases  have  been  benefited  by 
lavage  and  cured  by  stomach  drainage  (gastro-enterostomy). 

*  Med.  Rec,  Oct.  9,  1909;  Ibid.,  June  lo,  1911,  and  N.  Y.  Med.  Jour.,  May  ii,  1912. 

28 


434  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Amato  reports  a  case  of  gastric  tetany  with  death.  He  has  intro- 
duced fermenting  materials  into  the  stomachs  of  animals  and  produced 
dyspnea,  myosis,  muscular  contraction,  and  trismus.  The  liver  and 
pancreas  (postmortem)  showed  lesions,  such  as  are  usually  found  with 
poisonings  and  intoxications. 

Symptoms. — There  are  tonic  and  clonic  bilateral  spasms,  which  ap- 
pear suddenly  and  are  generally  confined  to  the  extremities,  the  flexor 
muscles  being  chiefly  affected.  The  fingers  are  bent  at  the  metacarpo- 
phalangeal joint,  extended  at  the  terminal  joints,  being  pressed  close 
together,  and  the  thumb  is  contracted  into  the  palm  of  the  hand.  The 
wrists  are  flexed,  the  elbows  bent,  and  frequently  the  arms  are  folded 
over  the  chest.  The  knees  are  bent,  the  feet  extended,  and  the  toes 
adducted. 

In  severe  cases  there  may  be  trismus,  and  the  angles  of  the  mouth  are 
drawn  up.     There  is  sometimes  edema  of  the  hands  and  feet. 

The  spasms  are  usually  paroxysmal  and  last  for  a  variable  time.  The 
eyes  may  be  turned  up. 

In  the  acute  attack  there  may  be  a  rise  of  temperature  and  elevation 
of  the  pulse.  In  some  cases  there  may  be  involvement  of  the  muscles 
of  the  back  and  of  the  thorax,  with  dyspnea  and  cyanosis. 

The  attacks  may  be  acute,  from  a  few  minutes  to  several  hours,  but 
there  may  be  some  stiffness  and  contraction  lasting  several  weeks. 

Diagnosis. — There  are  certain  diagnostic  features: 

(i)  *^  Trousseau's  Symptom.'' — As  long  as  the  attack  is  not  over,  the 
paroxysms  may  be  produced  by  compressing  the  affected  parts,  either  in 
the  direction  of  their  principal  nerve-trunk  or  over  their  blood-vessels, 
so  as  to  impede  the  venous  or  arterial  circulation. 

(2)  "Chvostek's  Symptom." — There  is  an  increase  in  the  mechanical 
excitability  of  the  motor  nerves.  A  slight  tap  over  the  facial  nerve  will 
throw  the  muscles  to  which  it  is  distributed  into  active  contraction. 

(3)  "Erb's  Sign." — The  electric  irritability  of  the  motor  nerves,  to 
the  galvanic  current  especially,  is  increased. 

(4)  '^ Hoffmann's  Sign." — Heightened  excitability  of  the  sensory  nerves. 
The  slightest  pressure  may  cause  paresthesia  in  the  region  of  distribution. 

The  prognosis  of  tetany  is  extremely  bad. 

Frequency. — Moynihan  believes  it  to  be  not  so  very  rare,  and  reports 
14  cases  in  which  gastro-enterostomy  was  performed,  with  a  cure  in  each 
case;  though  some  claim  only  30  to  40  cases  are  reported. 

Tetany-like  attacks  with  epileptiform  attacks  are  more  frequent,  and 
will  be  referred  to  under  Epilepsy. 

Treatment. — Bromids,  and  even  chloroform  inhalation,  during  the 
acute  attack  are  of  value.    Lavage  is  beneficial. 

The  chief  indication  is  drainage  of  the  stomach  by  gastro-enterostomy. 

REFERENCES 

Smith,  Med.  Rec,  1900,  Iviii,  910. 

Dujardin-Beaumetz,  L'Union  Medicale,  1884,  Nos.  15  and  18. 

Strong,  Boston  Med.  and  Surg.  Jour.,  1902,  cxlvii,  561,  597. 

Simpson,  Pract.,  1900,  Ixv.,  283. 

Kussmaul,  Deutsch.  Archiv  f.  klin.  Med.,  1869,  Bd.  6. 


CONVULSIONS — EPILEPSY  435 

Moynihaji,  Pract.,  1903,  Ixx,  354. 

Bouveret,  Rev.  de  Med.,  1892,  p.  48. 

Ewald,  Berl.  klin.  Wochens.,  1894,  No.  2. 

Fleiner,  Arch.  f.  Verdauungskrankheiten,  Bd.  i,  Heft  3. 

Einhorn,  Diseases  of  the  Stomach. 

Amato,  La  Riforma  Med.,  Feb.  4,  1903. 

E.  Neumann,  Deutsch.  Klinik,  1861. 

Boas,  loc.  cit.,  107,  and  others. 

CONVULSIONS— EPILEPSY 

Epileptic  seizures  occur  both  in  cases  of  chronic  ectasy  and  in  other 
affections  of  the  stomach.  I  have  had  a  case  under  observation  at  the 
Ma^nhattan  State  Hospital  who  suffered  from  repeated  attacks  of  epilepsy, 
140  seizures  a  month.  There  was  dilatation  of  the  stomach,  with  ptosis 
and  hypochlorhydria.  For  the  last  three  years,  while  having  occasional 
lavage,  dietetic  treatment  with  medication  directed  to  the  stomach,  no 
bromids,  she  has  had  no  attacks,  except  for  the  period  of  a  week,  over 
two  years  ago,  when  the  treatment  was  omitted.  The  mental  condition 
cleared  up,  and  the  patient  was  recently  discharged.  At  the  same 
institution  there  is  another  patient  with  atonic  ectasia  and  hypochlor- 
hydria, who  had  frequent  epileptic  attacks  and  who  has  had  no  seizures 
for  over  two  years,  as  a  result  of  treatment  directed  to  the  gastro-intestinal 
tract. 

I  have  reported  a  case  of  hyperchlorhydria,*^  with  epileptic  seizures, 
apparently  cured  by  appropriate  treatment;  and  cases  of  dementia 
paralytica  with  chronic  ectasy,  in  which  the  convulsions  were  diminished 
under  treatment  and  the  high  temperatures  returned  to  normal.  I  have 
also  seen  tetany-like  convulsions  in  a  case  of  dementia  praecox,  with  gastrop- 
tosis  and  marked  ectasy,  improve  after  treatment  of  the  stomach.  Salt- 
free  diet,  the  avoidance  of  meat,  open  air,  and  treatment  appropriate  to 
the  gastric  findings  in  each  case  are  indicated. 

In  conclusion,  I  cannot  recommend  too  highly  the  sour-milk  diet  in 
the  treatment  of  these  cases.  Matzoon,  koumiss,  kefir,  fermillac,  or  the 
lactone-buttermilk  can  be  employed  after  the  manner  indicated  under 
Atonic  Ectasy.  I  have  found  Wm.  H.  Thomson's  formula  for  the 
preparation  of  matzoon  of  great  value  in  these  cases.     It  is  as  follows: 

"i.  Place  half  a  cake  of  yeast  in  i  pint  (500  c.c.)  of  fresh  milk  in  a 
pitcher  covered  with  a  towel  in  a  warm  place  for  twelve  hours;  then 

"2.  Add  to  this  i  quart  (liter)  of  milk  and  keep  in  a  warm  place  for 
twelve  hours;  then 

"3.  Take  i  pint  (500  c.c.)  of  No.  2,  add  to  it  i  quart  (liter)  of  milk, 
and  keep  in  a  warm  place  for  twelve  hours;  then 

"4.  Take  i  pint  (500  c.c.)  of  No.  3,  add  to  it  i  quart  (Hter)  of  milk, 
and  keep  in  a  warm  place  for  twelve  hours. 

"This  makes  i^^  quarts  (1500  c.c.)  of  matzoon,  the  entire  process 
occupying  forty-eight  hours. 

"One  quart  (liter)  of  this  can  be  administered  in  divided  doses  daily, 

^  Observations  on  the  Relation  of  the  Gastro-intestinal  Tract  to  Nervous  and 
Mental  Diseases,  reported  April  17-21,  1905,  American  Medicopsychological  Associa- 
tion, and  in  their  proceedings. 


436  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

breaking  in  it  stale  bread  or  crackers,  and  eating  it  with  a  spoon.  The 
remaining  pint  (500  c.c),  with  the  addition  of  i  quart  (Uter)  of  milk  at 
the  end  of  twelve  hours,  will  furnish  i}4  quarts  (1500  c.c.)  of  matzoon. 
Fresh  matzoon  can  be  made  daily  from  the  former  pint  (500  c.c.)  of  mother 
matzoon  for  about  two  weeks,  when  the  process  must  be  started  over  again. 
If  larger  quantities  are  to  be  used,  i  quart  (liter)  of  No.  2  can  be  used  with 
2  quarts  (liters)  of  milk,  and  so  on." 

This  method  has  been  extensively  employed  by  Thomson  and  the 
author  in  feeding  our  epileptics.  One  can  also  use  4  to  6  ounces  (125- 
185  c.c.)  of  the  ordinary  bottled  matzoon  to  i  quart  (liter)  of  milk,  which 
will  produce  matzoon  if  kept  twelve  hours  in  a  warm  place.  From  this 
daily  matzoon  can  be  made  from  each  previous  supply  for  about  a  week, 
when  a  fresh  bottle  must  be  employed. 


CHAPTER  XVI 


ANOMALIES  IN   THE  POSITION   AND  FORM  OF  THE 
STOMACH— HOUR-GLASS  STOMACH— DISLO- 
CATIONS—GASTROPTOSIS 

Anomalies  of  form  are  frequently  congenital.  Fore-stomach  is  a 
dilatation  of  the  lower  end  of  the  esophagus  immediately  above  the 
diaphragm.  Antrum  cardiacum  is  a  sacculated  diverticulum  of  the 
esophagus  situated  below  the  diaphragnj.  In  some  cases  no  symtoms 
occur;  in  others  food  becomes  lodged  and  causes  serious  results.  Megalo- 
gastria  is  a  congenital  or  acquired  large  stomach  with  normal  functions. 
Microgastria  is  an  abnormally  small  stomach  with  normal  functions. 
Angustatio  ventriculi  is  an  extremely  small  stomach  due  to  stricture  of 
the  cardia  or  esophagus  or  to  cirrhosis  ventriculi. 

Congenital  Narrowing  of  the  Pylorus. — This  condition  is  due  to  hyper- 
trophy of  the  circular  muscles  of  the  pylorus  It  may  be  of  so  severe  a 
type  that  ingestion  of  food  may  be  impossible  and  the  infant  die  within  a 
few  days  after  birth.  In  milder  cases  chronic  ectasy  may  result  according 
to  some.  , 

HOUR-GLASS  STOMACH 

This  condition  may  be  congenital,  but  is  more  frequently  acquired. 
The  stomach  has  a  peculiar  sacculated  outline,  and  is  divided  into  two 
parts — the  cardiac  and  pyloric  (Fig.  214).     In 
some  cases  the  cardiac  sac  is  larger,  in  others, 
the  pyloric. 

Hour-glass  contraction  may  occur  as  con- 
genital, acquired  or  organic,  spastic  (or  hy- 
pertonic) and  hypotonic.  The  congenital 
form  is  extremely  rare. 

Etiology  of  the  Acquired  or  Organic  Type. 
— Cicatrized  tissue  contraction  following  an 
ulcer;  less  frequently  perigastric  (peritonitic), 
adhesions,  gastritis  from  corrosive  poisons, 
and  carcinoma  are  causes.  Slight  forms  may 
produce  no  characteristic  symptoms.  In  ad- 
vanced cases  the  division  may  be  recognized. 
By  the  ingestion  of  bismuth  and  the  use  of 
the  fluoroscope  with  the  A;-rays  this  condition 

can   be  demonstrated.     It  is  advised  to  secure  a  rontgenograph  when 
possible. 

Symptoms. — There  may  be  the  previous  history  of  ulcer,  perigastritis, 
corrosive  poisons  or  cancer,  followed  by  symptoms  of  stenosis  of  the  cardia 
or  pylorus. 

437 


Fig.  214. — Hour-glass  stomach. 


438  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

The  following  diagnostic  points  are  of  value: 

With  lavage,  part  of  the  fluid  is  lost  (Wolfler's  first  sign) ;  if  the  stomach 
is  washed  clean,  a  sudden  reappearance  of  the  stomach  contents  takes 
place  often  cloudy  in  character,  "  paradoxical  dilatation "  (Wolfler's 
second  sign)  which  suggests  the  passage  of  contents  from  the  pyloric 
pouch  into  the  cardiac  pouch.  When  the  stomach  has  been  apparently 
emptied,  a  splashing  sound  may  be  elicited  by  palpation  of  the  pyloric 
segment;  after  distending  the  stomach,  a  change  in  the  position  of  the 
distention  tumor  may  be  seen  in  some  cases.  Gushing,  bubbling,  or  siz- 
zling sounds  are  heard  on  dilatation  with  carbonic  acid  gas  at  a  point 
distinct  from  the  pylorus.     With  inflation  with  gas,  the  upper  pouch 


Fig.  215. — Hour-glass  stomach.  Female  aged  forty-three.  Operation  by  Dr. 
Walton  Martin  showed  the  presence  of  a  band  of  omentum  adherent  to  the  liver,  near 
the  site  of  a  former  operation.     (Bastedo  and  Le  Wold. ) 

will  first  distend,  and  then  subside  with  more  general  dilatation.  In 
some  cases,  when  both  parts  are  dilated,  two  tumors  with  a  notch  or  sulcus 
between  are  apparent  to  sight  and  touch.  On  both  sides  of  the  furrow 
there  will  be  a  loud  tympanitic  sound  which  cannot  be  elicited  in  the 
middle. 

Stockton  finds  that  if  the  first  part  of  the  stomach  is  aspirated,  after 
manipulation,  it  is  sometimes  possible  to  force  from  the  second  into  the 
first  portion  a  gastric  juice  of  different  quality. 

Radiography. — In  the  majority  of  cases  the  stomach  is  divided  into 
two  pouches,  generally  3  or  4  inches  from  the  pylorus.  Occasionally  a 
tripartite  stomach  is  found.     It  may  assume  various  irregular  shapes, 


DISLOCATION    OF    THE    STOMACH  439 

sometimes  appearing  like  a  saddle  bag.  In  corrosive  poison  cases  there 
may  also  be  deformity  at  the  pylorus  or  in  the  duodenum.  The  neck 
usually  does  not  emerge  from  the  most  dependent  portion  of  the  upper  sac, 
btU  from  a  poitit  higher  up.  In  Fig.  215  is  demonstrated  a  radiograph  of 
an  hour-glass  stomach. 

Spastic  Hour-glass  Stomach. — With  pyloric  stenosis  when  there  is 
increased  (hypertonic)  peristalsis,  a  contraction  may  be  seen  separating 
the  pyloric  end  from  the  rest  of  the  stomach.  Though  it  may  have  an 
hour-glass  appearance;  the  neck  comes  from  the  most  dependent  portion, 
the  construction  rings  are  equal  and  the  hour-glass  appearance  does  not 
appear  in  all  the  radiographs — thus  differing  from  the  organic  type. 

In  other  cases,  with  ulcer  of  the  lesser  curvature,  a  deep  incisura  is 
seen  in  the  greater  curvature.  This  is  liable  to  indicate  hepatic  adhesion 
and  the  incisura  is  spastic  and  often  disappears  when  the  patient  lies  down. 
Thus  spastic  contracture  sometimes  occurs  when  there  are  no  adhesions. 
Sometimes  the  greater  curvature  may  be  drawn  up  by  adhesions  and  the 
radiograph  appear  to  be  hour-glass  on  standing  but  this  disappears  when 
the  x-Ta,y  is  employed  in  the  Trendelenburg  position. 

Hjrpotonic  Hour-glass  Stomach. — Hertz  describes  a  ptosed  and  atonic- 
ally  dilated  stomach  which  sags  so  extremely  that  in  the  radiograph  the 
lower  segment  contains  bismuth — the  walls  meet  above  this  obliterating 
the  lumen  and  some  bismuth  accumulates  above. 

This  gives  an  apparent  hour-glass  stomach  which  disappears  when  the 
patient  lies  down  or  if  the  shoulders  are  depressed  (moderate  Trendelen- 
burg). 

Operative  procedure  is  the  only  method  of  cure. 

DISLOCATION  OF  THE  STOMACH 

The  fundus  may  be  dislocated  upward.     Among  the  causes  are: 

Absorption  of  a  pleuritic  exudate  on  the  left  side;  after  contraction 
of  the  lung  or  any  process  which  is  accompanied  by  upward  dislocation 
of  the  diaphragm;  excessive  distention  of  the  abdominal  cavity,  forcing 
the  diaphragm  upward,  such  as  from  pregnancy,  ascites,  tumors,  and 
raeteorism  and  diaphragmatic  hernia. 

The  cardiac  end  of  the  esophagus  may  become  bent.  Lateral  dis- 
location is  rare,  and  may  be  caused  by  tumors  of  the  spleen,  distended 
colic  flexure,  or  lateral  pressure  from  an  enlarged  liver.  As  a  rule,  the 
latter  forces  the  stomach  downward. 

Downward  dislocation  (gastroptosis)  is  the  common  form. 

DIAPHRAGMATIC  HERNIA.     EVENTRATION  OF  THE 
DIAPHRAGM.     VOLVULUS  OF  THE  STOMACH 

Diaphragmatic  Hernia.  With  this  condition,  the  stomach  and 
colon  are  most  frequently  involved  though  diaphragmatic  hernia  of 
nearly  all  the  viscera  may  occur.  In  the  majority  of  cases  there  is 
more  or  less  torsion  of  the  stomach  in  the  vertical  or  longitudinal  axis,  in 
addition  to  its  upward  displacement,  and  the  colon  may  lie  above  it. 


440  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

This  type  of  hernia  may  be  congenital  through  some  defect  of  develop- 
ment; or  acquired  in  which  event  the  hernia  takes  place  through  one  of 
the  normal  openings  in  the  diaphragm,  chiefly  through  the  esophageal 
opening — and  there  is  a  true  hernial  sac.  Finally,  there  may  be  traumatic 
hernia  due  to  laceration  of  the  diaphragm  from  wounds  by  knife  or  bullet, 
crushing,  or  severe  blows  or  falls.  If  a  portion  of  the  stomach  form  the 
hernia,  or  torsion  of  the  organ  is  marked,  strangulation  and  gangrene 
may  occur,  or  the  esophagus,  pylorus  or  duodenum  may  be  occluded. 

Symptoms — In  congenital  cases  they  may  appear  soon  after  birth, 
there  being  cyanosis,  dyspnea,  cardiac  misplacement  to  the  right,  inter- 
ference with  left  lung  expansion  and  rapid  death.  Occasionally  there 
are  milder  cases,  or  the  symptoms  develop  later  in  life.  In  these  there 
are  digestive  disturbances,  attacks  of  pain  and  vomiting  of  yellow  fluid, 
later  of  blood,  increased  tympany  in  the  anterior  axillary  line,  at  times 
jaundice,  distention  in  the  upper  left  quadrant  of  the  abdomen.  Relief 
may  follow  vomiting,  or  sudden  death  may  follow  from  gas  pressure  on 
the  heart,  or  peritonitis  may  result. 

In  the  acquired  cases,  symptoms  of  less  severe  type  may  occur  as  noted 
above  or  there  may  be  sudden  strangulation  with  its  symptoms,  hemate- 
mesis,  etc,  or  in  some  cases  obstruction  of  the  esophagus  with  distention 
and  no  vomiting. 

In  the  traumatic  cases,  the  symptoms  follow  the  injury,  or  may  occur 
later,  such  as  dyspnea,  thoracic  and  epigastric  pain,  cyanosis,  shallow 
breathing;  vomiting  or  attempts  to  vomit  if  torsion  of  the  esophagus,  with 
distention  and  marked  thirst.  In  the  chronic  types  there  are  attacks  of 
recurrent  vomiting  and  pain  after  meals — the  latter  worse  in  the  erect 
p)Osture.  Subsequently  if  strangulation  occur  there  may  be  hematemesis, 
or  inability  to  swallow  if  the  esophagus  is  obstructed,  collapse,  and  per- 
forative peritonitis. 

Diagnosis. — The  physical  signs  are  distention  of  the  chest  on  the  af- 
fected side,  restriction  in  pulmonary  expansion,  intestinal  peristaltic  move- 
ments communicated  to  the  thorax  (in  some  cases) ;  epigastrium  retracted 
or  distended  depending  on  the  degree  of  hernia,  and  rigidity  of  the  upper 
abdominal  wall.  There  may  be  a  tympanitic  note  at  the  base  of  the  lung, 
or  a  dull  area  due  to  the  spleen,  omentum  or  fluid  contents  of  the  stomach. 
Artificial  distention  of  the  stomach  and  colon  increase  the  tympanites. 
Gurgling  sounds  are  present  over  the  stomach,  respiratory  sounds  are  no 
longer  distinct.  Compression  of  the  lung  occurs  above  the  hernia  and  the 
heart  is  usually  displaced  to  the  right. 

Radiographs. — If  the  colon  forms  part  of  the  hernia,  bismuth  or  barium 
enema  will  demonstrate  its  presence  above  the  Hne  of  the  diaphragm.  The 
bismuth  meal  will  show  a  curved  shadow  line  with  the  concavity  down- 
ward, i.e.,  the  upper  wall  of  the  stomach.  Below  this  is  usually  an  air 
bubble  which  in  turn  lies  above  the  diaphragm  level.  With  diaphrag- 
matic hernia  there  is  a  mottled  appearance  of  lung  tissue  visible  through 
the  gas  lying  in  the  stomach,  which  does  not  occur  with  eventration  of  the 
stomach  (Giffin). 

Paradoxical  Expiratory  Displacement. — On  forced  inspiration  the  dia- 
phragm descends  normally  on  the  right  side,  but  on  the  left  side  it  ascends. 


GASTROPTOSIS — ENTEROPTOSIS — GL^NARD's  DISEASE     441 

On  forced  expiration  the  reverse  occurs,  and  the  shadow  line  on  the  left 
side  is  found  high  up. 

Differential  Diagnosis. — With  eventration  of  the  stomach,  the  mottled 
appearance  of  lung  tissue  is  not  visible  in  the  radiograph  through  the  gas 
in  the  stomach,  as  it  is  with  diaphragmatic  hernia.  The  shadow  lines  in 
the  radiograph  or  by  fluoroscopy  may  give  information.  With  two  curved 
shadow  lines,  if  after  artificial  distention  of  the  stomach,  the  lower  one 
move  upward  against  the  upper,  then  the  lower  is  stomach  and  the  upper 
diaphragm.  If  the  upper  Hne  was  stomach,  then  it  would  move  up  higher 
after  distention.  However,  a  single  shadow  line  may  represent  both 
stomach  and  diaphragm,  but  distention  will  cause  the  pyloric  end  of  the 
stomach  to  unfold. 

Recurrent  attacks  of  pain  and  vomiting  after  injury  to  the  lower  thorax 
point  to  hernia.  With  pneumothorax  we  have  the  physical  signs,  and  fre- 
quently signs  in  the  other  lung;  there  are  fewer  gastric  symptoms.  Radio- 
graphs show  an  unbroken  line  of  the  diaphragm  and  no  bismuth  or  barium 
deposit  above  it. 

With  subphrenic  abscess,  there  is  a  previous  history  of  gastric  or  duo- 
denal ulcer;  leukocytosis  and  increased  polynuclears  are  present.  The 
.T-rays  show  the  stomach  below  the  diaphragm. 

Prognosis. — ^This  is  grave  in  all  cases,  though  operation  after  early 
diagnosis,  has  proved  successful. 

Treatment. — For  acute  distention  with  cyanosis,  lavage  affords  tem- 
porary relief  providing  the  esophagus  is  patent.  Surgical  procedure  is 
indicated. 

Eventration  of  the  Diaphragm. — -This  consists  in  a  thinning  and 
weakening  of  the  diaphragm  usually  on  the  left  side,  so  that  it  bulges 
upward  and  forms  a  sac  into  which  the  stomach  or  other  viscera  may 
enter.  The  condition  is  often  congenital  and  lack  of  development  of  the 
left  lung  is  associated.  It  may  be  acquired  by  atrophy  or  degeneration 
of  the  muscle  of  the  diaphragm,  or  as  a  result  of  paralysis  of  the  phrenic 
nerve. 

Radiograph. — This  shows  a  high  line  of  the  diaphragm  unbroken  and 
overlying  the  bismuth  area  in  the  stomach. 

Symptoms. — These  are  not  characteristic  and  the*  physical  signs  re- 
semble those  of  hernia  (diaphragmatic)  which  are  described  under  that 
section. 

Treatment. — Only  symptomatic  treatment  can  be  employed. 

Volvulus  of  the  Stomach. — This  consists  of  an  abnormal  rotation  of 
the  stomach  on  one  or  more  of  its  axes,  resulting  in  the  occlusion  of  one 
or  both  of  its  orifices  (the  pylorus  most  frequently).  The  volvulus  may 
be  partial  or  complete.  While  the  cardia  is  still  patent  vomiting  occurs 
and  lavage  affords  relief.  Later  cardiac  occlusion  occurs  and  the  tube 
can  no  longer  be  passed. 

Axial  rotation  is  usually  from  below  forward  and  upward,  the  anterior 
form,  and  less  frequently  from  below  backward  and  upward,  the  pos- 
terior form.  Rotation  about  the  vertical  axis  is  less  frequent  and  then 
more  generally  from  right  to  left.  The  degree  of  rotation  varies;  mild 
cases  with  pain,  distention  and  vomiting  may  spontaneously  recover.    The 


442  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

rotation  is  usually  i8o  degrees  or  more  producing  strangulation,  the 
stomach  becoming  greatly  distended. 

Etiology. — Among  the  causes  are  diaphragmatic  hernia,  tumors,  hour- 
glass stomach,  adhesions,  trauma  produced  by  displacement  of  liver  or 
spleen,  a  blow  or  a  fall;  gastroptosis  has  been  given  as  a  cause  but  I  doubt 
it.     Some  so-called  idiopathic  (non-explainable)  cases  are  reported. 

Symptoms. — There  are  the  previous  symptoms  of  hour-glass  stomach, 
adhesions,  or  diaphragmatic  hernia  in  some  cases.  In  others  there  is 
sudden  intense  and  continuous  pain  in  the  epigastrium  or  lower  left 
thoracic  region  ("douleur  thoracique"  as  described  by  Faure)  with  severe 
pressure  over  the  heart  as  if  the  thorax  would  break;  vomiting,  often 
hematemesis;  later  the  vomiting  stops  and  distention  increases  and  it  is 
impossible  to  pass  a  stomach- tube,  due  to  torsion  of  the  esophagus.  There 
is  an  effort  to  vomit  but  no  ability  to  do  so.  Localized  rigidity  of  ab- 
dominal muscles  appears  early  and  spreads.  Death  occurs  from  collapse 
or  peritonitis. 

Differential  Diagnosis. — With  diaphragmatic  hernia,  there  are  the 
usual  signs,  with  heart  displaced  to  the  right. 

With  intestinal  obstruction — vomiting  persists  while  with  volvulus  it 
stops  and  the  stomach-tube  is  blocked.  This  last  also  differentiates  it  from 
acute  dilatation  of  the  stomach  where  the  tube  is  readily  passed  and 
affords  relief.  With  acute  pancreatitis  we  have  epigastric  peritonitis, 
tenderness  at  Robson's  and  other  points,  subnormal  temperature,  general 
hemorrhagic  tendency,  jaundice,  the  history,  etc. 

Prognosis  is  bad  as  a  rule. 

Treatment. — Early  lavage  when  possible  may  aid  in  spontaneous  re- 
duction.    Surgery  is  otherwise  indicated. 

GASTROPTOSIS— ENTEROPTOSIS—GLENARD'S   DISEASE 

(Synonyms. — Gastroptosis — Rose;  Visceroptosis;  Splanchnoptosis;  Abdominal  Relaxa- 
tion or  Atonia  Gastrica  — Rose;  Atony  of  the  Third  Degree) 

Definition. — Gastroptosis  may  be  defined  as  a  prolapse  or  downward 
displacement  of  the  stomach,  right  kidney  or  both  kidneys,  and  other 
organs  of  the  abdominal  cavity,  which  may  be  associated  with  disturbances 
of  the  gastro-intestinal  tract  and  pelvic  organs,  together  with  various 
nervous  symptoms.     Ptosis  of  the  heart  may  also  occur. 

Nephroptosis  is  a  stigma  of  gastroptosis. 

Introduction. — I  here  use  the  term  "gastroptosis"  with  the  usual 
definition  (ptosis  of  the  stomach),  though  Rose  has  shown  it  correctly 
means  descent  of  the  belly  (spalnchnoptosis).  The  reader  must  remember 
that  gastroptosis  is  a  quite  frequent  condition,  and  that  it  may  be  acci- 
dentally discovered  in  some  cases  which  have  no  symptoms  whatever. 
On  the  other  hand,  there  are  various  degrees  of  ptosis  of  the  stomach,  in 
some  of  which  the  symptoms  are  rather  mild  in  character,  while  in  others 
there  may  be  the  symptoms-complex  of  Glenard's  disease. 

It  is  not  the  position  of  the  lower  border  of  the  stomach  which  con- 
stitutes a  ptosis,  but  that  of  the  upper  border;  with  the  relaxation  of  the 
suspensory  ligaments  of  the  stomach  the  lesser  curvature  sinks  as  well  as 


GASTROPTOSIS — ENTEROPTOSIS GLENARD's   DISEASE  443 

the  greater,  and  we  may  have  varying  degrees  of  ptosis,  from  moderate 
obliquity  of  the  upper  border,  to  a  vertical  stomach;  while  on  the  other 
hand,  the  entire  organ  may  sink  and  give  the  crescentic  form  of  gastro- 
ptosis.  The  determination  of  the  lower  border  alone  is  not  diagnostic, 
since  it  may  merely  be  evidence  of  a  dilated  stomach.  Hundreds  or 
even  thousands  of  cases  of  nephroptosis  have  been  reported  as  having 
dilated  stomachs,  the  dilatation  being  imputed  to  pressure  of  the  kidney 
on  the  duodenum,  and  no  investigation  has  been  made  of  the  position 
of  the  lesser  curvature. 

From  my  own  experience,  I  do  not  hesitate  to  say  that  movable  kidney 
(nephroptosis),  with  the  lower  border  of  the  stomach  lower  than  normal, 
is  diagnostic  of  gastroptosis.  Dilatation  of  the  stomach  is  often  associated 
with  gastroptosis,  but  kidney  pressure  on  the  duodenum,  in  my  opinion, 
has  no  bearing  as  to  its  production.  This  combination  has  been  found  in 
cases  at  the  Manhattan  State  Hospital.  Furthermore,  treatment  for 
gastroptosis  will  generally  cure  this  condition.  Ptosis  of  the  stomach  in 
some  of  these  cases  may  be  of  extremely  mild  type. 

Anatomic  Considerations. — It  is  necessary  to  briefly  allude  to  certain 
anatomic  features.  The  liver,  as  we  know,  is  suspended  from  the  dia- 
phragm by  ligaments  derived  from  the  peritoneum.  The  cardiac  end  of 
the  stomach  is  held  quite  fixedly  in  position  by  the  esophagus,  and  there 
is  a  peritoneal  attachment  to  the  diaphragm  at  this  point,  the  gastro- 
phrenic ligament.  In  this  location  the  stomach  lies  in  close  relation  to  the 
diaphragm,  while  the  lesser  curvature  is  suspended  from  the  liver  by  the 
lesser  omentum  (gastrohepatic).  The  spleen  lies  in  close  relation  to  the 
diaphragm,  being  attached  thereto  by  ligaments  (processes  of  the  peri- 
toneum), and  to  the  stomach  by  the  gastrosplenic  omentum. 

It  is  thus  readily  understood  how  compression  of  the  lower  part  of 
the  thorax  or  effusions  above  the  diaphragm  may  mechanically  force  down 
the  latter  and  produce  ptosis  of  organs  so  closely  associated.  The  descent 
of  the  intestines  is  a  natural  accompaniment. 

A  tumor  of  the  pylorus  may  cause  ptosis  of  the  stomach,  and  prolapse 
of  the  transverse  colon  and  of  the  other  viscera  follow. 

On  the  other  hand,  a  severe  type  of  dilatation  of  the  stomach  may 
be  followed  by  ptosis  of  the  organ  and  then  general  visceroptosis.  These 
primary  types  of  gastroptosis  are  not  so  very  frequent. 

The  transverse  mesocolon  surrounds  the  transverse  colon  and  con- 
nects it  with  the  back  of  the  abdomen  at  the  spine.  The  transverse  colon 
is  attached  to  the  abdominal  surface  of  the  eleventh  rib  on  each  side  by 
a  fold  of  peritoneum.  As  the  colon  passes  across  the  abdomen  it  sags 
somewhat,  presenting  a  slightly  concave  surface  superiorly.  Glenard, 
whom  we  must  justly  credit  as  the  first  to  describe  splanchnoptosis  as  a 
pathologic  entity,  believes  enteroptosis  (ptosis  of  the  transverse  colon) 
to  be  the  starting-point.  He  thinks  the  transverse  colon  is  fastened  to 
the  pyloric  end  of  the  stomach  by  a  band  (ligament),  and  that  the  hepatic 
flexure  first  sags,  followed  by  the  transverse  colon,  causing  thus  a  sharp 
flexion  at  the  attachment  of  the  ligament,  and  a  hindrance  to  the  progress 
of  the  intestinal  contents,  with  resulting  accumulation  in  the  ascending 
and  transverse  colon.     From  the  point  of  stenosis  the  transverse  colon 


444  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

passes  downward  diagonally  across  the  abdomen  as  a  hard  cord-like  mass 
(corde  colique  transverse). 

The  sagging  of  the  transverse  colon  exercises  traction  on  the  pylorus 
and  omentum,  thus  causing  descent  of  the  stomach  and  liver.  The 
descent  of  the  hepatic  flexure,  he  beUeves,  causes  traction  on  the  parietal 
peritoneum  and  encourages  ptosis  of  the  right  kidney.  The  gastro- 
intestinal tract,  he  noted,  was  suspended  in  the  form  of  loops,  six  in 
number,  by  means  of  ligaments;  and  he  believed  in  the  possibility  of  too 
great  a  bend  at  such  an  acute  angle,  that  it  might  cause  a,  partial  obstruc- 
tion to  the  passage  of  the  contents.  This  might  occur  at  the  gastroduo- 
denal,  the  duodenojejunal,  transverse  colon,  or  sigmoidorectal  curves. 

The  gastroduodenal  and  transverse  colon  ligaments  Glenard  holds 
to  be  the  weakest,  and  if  they  give  way,  with  resulting  ptosis  of  the  in- 
testine, increased  traction  and  angulation  is  produced  at  the  next  fixation 
point,  causing  an  enterostenosis. 

Glenard  found  the  transverse  colon  displaced  and  stenosed  in  numerous 
autopsies,  and  was  the  first  to  realize  that  many  cases  of  so-called  nervous 
dyspepsia  were  dependent  upon  these  abnormahties. 

Riegel  has  demonstrated  that  the  hepatic  flexure  is  not  dislocated 
downward  in  the  majority  of  cases,  and  Glenard's  explanation  I  hardly 
believe  tenable,  as  there  are  other  very  important  factors  which  have  a 
bearing.  A  tumor,  however,  of  the  transverse  colon  or  adhesions  may 
produce  primary  enteroptosis. 

We  must  remember  there  is  one  type  of  case,  a  congenital  constitutional 
defect,  the  patient  with  long  narrow  thorax,  who  suffers  from  splanchno- 
ptosis. 

Keene  finds  in  autopsies  on  babies  evidences  in  favor  of  the  congenital 
origin  of  enteroptosis.  In  many  of  these  there  was  a  redundant  colon. 
A  potential  enteroptosis  is,  therefore,  present,  which  is  latent.  Later, 
through  some  cause,  weakening  of  the  abdominal  musculature  or  diminu- 
tion of  intra-abdominal  pressure,  sagging  of  the  intestine  occurs  and 
symptoms  develop.  The  writer  believes  there  are  quite  a  number  of 
these  congenital  cases.  The  round-shouldered,  hollow-backed  position, 
Reynolds^  holds,  results  in  the  formation  of  pot-belly  and  leads  to  the 
production  of  splanchnoptosis.  Undoubtedly,  spinal  curvature  or  rickets 
may  be  factors. 

The  major  number  of  cases  of  gastroptosis,  however,  are  acquired  from 
various  causes;  and  in  my  opinion  the  development  of  the  prolapse  of  the 
various  organs  generally  occurs  synchronously,  the  stomach,  right  kidney, 
and  transverse  colon  most  frequently  prolapsing  together;  while  in  other 
cases  the  left  kidney  or  the  rest  of  the  viscera  may  descend  in  addition. 

These  following  are  the  prominent  factors  which  have  a  marked  bearing 
in  preserving  the  proper  position  of  the  viscera: 

1.  The  abdominal  muscles. 

2.  The  maintenance  of  normal  intra-abdominal  pressure. 

I.  Abdominal  Muscles. — In  an  interesting  article,  the  late  A.  Rose* 

^  Jour.  Amer.  Med-  Assoc.,  Dec.  3,  1910. 

*  Surgery,  Gynecology,  and  Obstetrics,  November,  1906,  Physiology  and  Pathology 
of  the  Abdominal  Muscles. 


GASTROPTOSIS ENTEROPTOSIS GL^INARD's    DISEASE  445 

calls  attention  to  the  fact  that  in  addition  to  the  usual  functions  described 
in  the  text-books,  in  assisting  expulsion  of  the  fetus,  bowel  action,  urina- 
tion, and  vomiting,  the  abdominal  muscles  aid  in  the  preservation  of  the 
physiologic  position  of  the  abdominal  organs.  The  crosswise  arrange- 
ment of  the  external  and  internal  oblique  and  transversalis  muscles — 
supported  by  the  recti — effect  a  narrowing  of  the  abdominal  cavity  and 
prevent  visceral  ptosis. 

Groddeck,  of  Baden-Baden,  has,  moreover,  described  the  mechanical 
influence  of  healthy  muscle,  by  the  alternate  contraction  and  expansion, 
in  assisting  the  circulation  of  the  blood  and  lymph,  and  an  atonic  condi- 
tion of  the  abdominal  musculature  would  certainly  interfere  with  the 
maintenance  of  the  normal  relations  between  the  extra-  and  intra- 
abdominal circulation.  Moreover,  clinically,  simple  inspection  will 
differentiate  between  normal  conditions  and  the  typic  "pot-belly"  of 
the  gastroptosis  patient.  Acute  or  wasting  disease  may  also  cause 
changes  in  the  muscles. 

2.  Intra-abdominal  Pressure. — Normal  abdominal  muscles  also  main- 
tain the  normal  intra-abdominal  pressure  necessary  to  preserve  the  posi- 
tion of  the  viscera. 

Walkow^  has  made  a  very  exhaustive  study  of  this  question  and  has 
demonstrated, /(?r  example,  on  the  cadaver,  with  the  upper  part  of  the  trunk 
elevated  (the  reversed  Trendelenburg  position),  that  after  abdominal 
section,  mobility  of  varying  degrees  of  the  kidney  is  found,  which  did  not 
previously  exist. 

Stiirmdorf  has  found  similar  results  after  laparotomy  on  the  living. 

Clinically,  changes  in  the  intrarabdominal  pressure,  the  result  of  child- 
birth or  tapping  for  ascites,  have  resulted  in  the  production  of  splanchno- 
ptosis, the  thinned  and  distended  musculature  of  the  abdomen  also  being  a 
factor. 

Rapid  loss  of  weight  from  emaciation  and  absorption  of  omental  fat  is 
another  example. 

Nephroptosis. — Movable  kidney,  in  probably  95  per  cent,  of  cases  in 
my  own  experience,  is  one  of  the  stigmata  of  gastroptosis.  The  congenital 
type,  with  long  mesonephron,  or  those  cases  due  to  traumatism,  are  com- 
paratively few  in  number. 

The  right  kidney  has  a  longer  pedicle  and  lies  lower  on  account  of  the 
liver. 

Stiirmdorf  refers  to  certain  skeletal  deformities  as  influencing  the  shape 
of  the  bony  receptacle  for  the  kidneys,  and  which  in  some  cases  predisposes 
to  prolapse;  but  gastroptosis  is  associated  with  these  same  conditions. 

It  has  been  claimed  that  there  is  a  nephrocolic  ligament  connecting 
the  kidneys  to  the  ascending  and  descending  colon,  and  that  traction  of 
the  colon  may  influence  its  descent.  Reversed  peristaltic  action  occurring 
intermittently  in  the  ascending  colon,  which  does  not  take  place  in  the 
descending,  is  believed  to  have  an  influence,  arid  the  peritoneum  over  the 
left  kidney  is  said  to  be  thicker.  The  fact  that  the  tail  of  the  pancreas 
lies  in  front  of  the  left  kidney  seems  to  me  to  have  some  bearing  on  the  ques- 
tion.    Absorption  of  the  fatty  capsule  is  probably  another  factor. 

^  Med.  Rec,  Jan.  13,  1906. 


446  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

The  peculiar  position  of  the  right  kidney  and  lessening  of  intra-ab- 
dominal pressure  seem  to  be  the  chief  causes  of  its  more  frequent  descent. 

With  gastroptosis  we  have  also  a  relaxation  of  the  gastro-intestinal 
musculature  and  of  all  the  peritoneal  ligaments.  Changes  in  the  position 
of  the  stomach  and  in  its  secretory  and,  at  times,  in  its  motor  functions 
account  for  the  gastric  disturbances.  The  secretory  function  one  might 
expect  to  be  influenced  by  circulatory  disturbances  following  displacement 
of  the  organ. 

Associated  are  changes  in  the  position  of  the  duodenum  productive  of 
stasis,  and  which  readily  account  for  gall-bladder  symptoms  simulating  stone, 
so  often  attributed  to  nephroptosis.  Similar  disturbances  in  the  intestine, 
constipation,  diarrhea,  mucous  colic,  or  chronic  appendicitis  can  thus  be 
accounted  for.  There  is  a  relaxation  of  the  broad  ligaments  and  with  it 
ovarian  and  uterine  descent,  and  even  descent  of  the  pelvic  floor,  with 
dysmenorrhea  and  various  symptoms  of  the  pelvic  organs.  I  do  not 
agree  with  Edebohls'  theory  of  compression  of  the  superior  mesenteric 
vein  by  the  kidney  as  a  cause  of  congestion  of  the  appendix. 

Occasionally,  Dietl's  crisis  from  torsion  of  the  kidney  pedicle  and, 
rarely,  nephritis  or  hydronephrosis  occur.  More  rarely  the  kidney  may 
become  adherent  to  the  gall-bladder  or  appendix.  In  addition,  circula- 
tory disturbances  and  marked  neurasthenia,  the  latter  due  chiefly,  I 
believe,  to  auto-intoxication,  are  present;  and  from  the  severe  type  of 
splanchnoptosis  we  have  the  symptoms-complex  of  Glenard's  disease — 
all  of  which  the  "kidney  experts"  attribute  to  nephroptosis. 

Etiology. — We  must  remember  that  the  vertical  stomach  is  the  fetal 
position  of  the  organ.  Some  hold  that  every  infant  is  born  with  it  in  this 
position  and  that  after  a  few  weeks  or  months,  through  the  weight  of  the 
food  and  the  action  of  the  diaphragm,  the  position  of  the  stomach  becomes 
normal.  Recently  radiographs  of  the  stomach,  of  very  young  infants  and 
children,  apparently  show  that  the  position  and  shape  of  the  infant  stom- 
ach is  not  always  constant,  though  the  normal  organ  lies  in  its  entirety 
above  the  umbilicus.  Occasionally,  it  may  remain  vertical,  but  I  believe 
this  is  true  more  especially  in  those  suffering  from  the  congenital  consti- 
tutional defect,  to  which  I  shall  refer. 

The  causes  of  gastroptosis  may  be  divided  into  congenital  and  acquired : 

I.  Congenital  constitutional  defect,  the  long  narrow  thorax,  with  the 
diaphragm  and  liver  pushed  down.  In  these,  splanchnoptosis  is  a  con- 
stitutional defect.  Stiller's  floating  tenth  rib  is  usually  present.  Butler,^ 
from  more  recent  investigations,  holds  that  the  floating  tenth  rib  is  rare 
in  adults;  though  fully  50  per  cent,  of  all  children  have  a  movable  tenth 
rib,  though  it  is  rarely  unattached.  Mobility  of  this  rib  is  not  a  stigma 
of  enteroptosis  in  children.  Butler  holds  that  the  ptoses  are  usually  first 
noted  at  the  period  of  puberty.  The  enteroptotic  habit  of  the  adult  finds 
its  counterpart  in  the  chUd,  with  frail  habit,  lack  of  fat,  slender  muscles 
and  lack  of  vigorous  bodily  development.  The  prolapse  of  the  organs  does 
not  usually  occur  in  children  under  twelve  years  of  age.  With  constitu- 
tional inferiority  vagotonia  is  believed  by  Eppinger  and  Hess  to  be  present. 
2.  Other  skeletal  deformities,  spinal  curvature,  rickets,  kyphosis  and  kypho- 
^  Enteroptosis  in  Children,  Jour.  Amer.  Med-  Assoc,  Dec.  31,  1910. 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD's   DISEASE  447 

scoliosis  are  contributory.  Lordosis,  Lerch^  believes  an  important  factor, 
and  that  the  large  overdistended  thymus  occurs  with  enteroptotics  and 
has  a  bearing  on  circulatory  and  nervous  disturbances.  3.  Intrathoracic 
pressure  on  the  diaphragm  from  effusions,  tumor,  etc.  4.  Tumors  of  the 
liver.  5.  Leukemic  enlargements  of  the  spleen.  6.  Tumor  of  the  pylorus 
or  adhesions  (gastric).  7.  Tumor  of  the  colon  or  adhesions.  8.  Chronic 
dilatation  of  the  stomach.  9,  Compression  of  the  thorax  by  tight  lacing, 
poor  corsets,  tight  waist-bands,  etc.  10.  Relaxation  of  the  abdominal 
muscles  and  diminution  of  intra-abdominal  pressure.  This  may  result 
from  rapid  emaciation  in  acute  diseases,  with  degeneration  of  the  muscular 
tissue;  or  the  same  condition  in  longer  chronic  wasting  diseases,  or  from 
loss  of  weight  and  muscular  tone  from  any  cause. 

Landau's  disease,  splanchnoptosis  following  confinement,  is  fairly  fre- 
quent. Emptying  of  the  uterus  produces  a  sudden  diminution  in  intra- 
abdominal tension,  and  the  tendency  of  the  viscera  is  to  fill  the  vacuum 
previously  occupied  by  the  uterus.  The  abdominal  walls  are  lax  and  thin 
from  uterine  pressure.  The  accoucheur  is  often  to  blame  for  not  properly 
supporting  the  relaxed  abdomen. 

Tapping  of  ascites,  with  removal  of  all  the  fluid,  may  produce  a  similar 
condition;  or  removal  of  large  tumors.  One  occasionally  finds  gastro ptosis 
in  women  who  have  become  obese,  especially  after  several  parturitions,  the 
abdomens  are  pendulous  and  the  musculature  soft  and  flabby.  The  treat- 
ment of  these  cases  differs  considerably  from  that  from  the  other  causes. 

Sex. — Meynert  found  in  50  girls,  aged  twelve,  50  per  cent,  gastroptosis, 
and  about  80  per  cent,  females  in  his  gynecologic  clinic  to  5  per  cent,  males 
among  adults. 

From  the  study  of  various  statistics  it  can  be  estimated  that  from 
about  20  to  25  per  cent,  of  women  complaining  of  digestive  disturbances 
are  affected  with  movable  kidney  and  enteroptosis.  Unquestionably  the 
percentage  of  gastroptosis  among  all  women,  including  those  who  complain 
of  no  symptoms,  will  average  at  least  15  per  cent,  in  our  city  population. 
The  advocates  of  nephropexy  find  nephroptosis,  disregarding  the  other 
ptoses,  in  20  to  33  per  cent,  of  all  women,  a  satisfactory  surgical  viewpoint. 

The  improvement  following  promiscuous  nephropexy  in  gastro-intes- 
tinal  and  other  symptoms  can  be  often  imputed  to  the  post-operative  rest 
in  bed  and  to  the  increase  in  fat  by  proper  feeding. 

The  ratio  of  males  complaining  of  digestive  disturbances,  with  entero- 
ptosis and  nephroptosis,  is  about  2  to  3  per  cent.  The  ratio  in  women  is 
8  or  10  to  one  male. 

Glenard  finds  a  lower  ratio,  70  women  to  30  men  in  100  cases. 

Age.^Th.Q.  most  frequent  age  is  from  eighteen  to  forty,  though  between 
fifty  to  sixty  the  condition  appears  most  marked. 

Sjntnptoms.— Gastroptosis  may  exist  without  the  production  of  any 
symptoms;  while  on  the  other  hand,  it  may  be  present  with  those  of  a 
mild  character,  or  may  finally  present  the  aggravated  type  of  Glenard. 
The  following  symptoms,  in  part  or  whole,  may  be  present:  Some  cases 
complain  chiefly  of  nervous,  cardiac,  gastro-intestinal  or  pelvic  disturb- 
ance, or  of  special  organs,  such  as  the  kidney  or  liver. 
1  N.  Y.  Med.  Jour.,  Dec.  19,  1914. 


448  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

There  are  usually  anemia,  a  feeling  of  weakness,  dizziness  or  faintness 
and  fatigue  on  slight  exertion  and  backache.  The  appetite  in  some  cases 
is  poor,  while  in  others  quite  good. 

Some  patients  have  the  symptoms-complex  of  hyperchlorhydria,  while 
others  complain  of  belching  and  discomfort  immediately  after  eating. 
There  are  usually  marked  and  obstinate  constipation,  rarely  diarrhea;  at 
times  intestinal  catarrh  or  mucous  colic.  Flatulence  is  present.  They 
have  headache,  are  frequently  nervous  and  hysteric,  and  at  times  neuras- 
thenic and  are  irritable  or  mentally  depressed.  There  is  often  a  feeling  of 
weight  or  bearing  down  in  the  abdomen,  which  is  relieved  by  proper  sup- 
port. Menstrual  disorders  are  frequently  present,  dysmenorrhea  quite 
often.  At  times  the  pain  and  discomfort  are  focused  in  the  kidneys, 
especially  the  right;  and  in  addition  they  may  have  attacks  of  Dietl's 
crisis.  Pains  in  the  region  of  the  liver  and  gall-bladder  occur  in  some,  and 
there  may  be  attacks  of  pain  resembling  gall-stones  and  occasional  jaun- 
dice, or  rheumatic,  or  neuralgic  pains,  or  pains  in  the  coccyx,  breast  or 
heart  region.     There  mav  be  irritability  of  the  bladder,  with  frequent 


Fig.  216. — Abdominal  projection;  lead-tape  outline  between  anterior  superior  spines; 
curved  line,  when  standing;  flat  line,  when  lying  on  back  (from  Gallant). 


inclination  to  urinate,  and  pains  or  tenderness  in  the  ovaries  and  appen- 
dical  region.  Various  sensitive  points  are  often  found  in  other  regions 
of  the  abdomen.  Paresthesia  or  hyperesthesia  may  occur  as  may  areas 
of  anesthesia.  There  are  sensory  or  vaso-motor  disturbances  in  others. 
Palpitation  is  frequently  present  and  occasionally  attacks  of  tachycardia 
may  occur. 

Slight  cases  of  gastroptosis  may  even  give  symptoms  pointing  to 
the  entire  gastro-intestinal  tract.  For  example,  Miss  H.  V.  H.,  age 
twenty-eight,  referred  to  me  by  Dr.  Wm.  Posey  of  Philadelphia,  com- 
plained chiefly  of  poor  appetite,  coated  tongue  and  diarrheal  attacks 
(three  to  four  movements  daily),  followed  by  constipation.  Systolic 
pressure  140,  high  for  that  age,  and  evidences  of  intestinal  putrefaction 
in  the  stool  and  urine.  There  was  slight  motor  insuflSciency  of  the 
stomach,  but  no  residuum  showed  in  the  radiograph  six  hours  after  the 
barium  meal.  The  gastric  analysis  was  within  normal  limits,  but  on  the 
border  of  excess  for  the  individual:  Total  acid  6o-|-;  free  Hcl  34+;  comb. 
Hcl  22  +  ;  acid  salts  4+;  no  occult  blood. 

X-rays,  slight  gastroptosis;  no  retention  of  barium  meal  at  six  hours; 
ptosis  of  the  hepatic  flexure  of  the  colon,  with  sharp  angulation,  no 
adhesions.     Heart  and  lungs  were  normal. 

Immediate  relief  was  afforded  to  the  bowel  condition,  by  Rose's 
belt  and  subsequently  by  correct  corsets,  evidently  by  elimination  of 
the  angulation.  I  imputed  more  to  this  than  to  the  simple  medication 
ordered.     The  increase  in  pressure  was  attributed  to  the  indicanuria  (in- 


GASTROPTOSIS — ENTEROPTOSIS GL^NARD's  DISEASE     449 

testinal  putrefaction),  so  red  meats  were  abolished.  Iron  tonic  was 
administered  for  the  anemia,  etc. 

Physical  Examination. — Inspection. — These  patients  are  usually  thin 
and  slender;  the  abdominal  walls  are  generally  flaccid.  The  angle  formed 
by  the  ensiform  and  lower  margins  of  the  thorax  is  sharp  (very  acute) 
in  the  congenital  cases,  with  a  long  narrow  thorax.  The  form  of  the 
patient  is  angular  and  the  muscles  are  thin.  There  is  a  concavity  be- 
tween the  costal  arches  in  the  epigastrium  from  the  ensiform  to  the 
umbilicus;  and  in  some  a  vertical  median  sulcus  between  the  recti 
muscles  wider  above  than  below. 

In  the  dorsal  position  the  abdomen  may  be  flattened  below  and  bulge 
laterally;  and  when  the  patient  is  erect  the  epigastrium  becomes  more 
depressed;  while  the  hypogastric  regions  from  the  umbilicus  to  the  sym- 
physis and  the  pubic  region  markedly  bulge  forward  and  outward  (pot- 
belly).    Fig.  216  shows  this  clearly. 

Palpation. — Diastasis  (separation  of  the  recti  muscles)  can  be  readily 
appreciated.  Stiller's  floating  tenth  rib  is  present  in  some  cases  (the 
congenital).  Marked  pulsation  of  the  abdominal  aorta  is  often  met  with 
as  it  is  uncovered  by  the  stomach.  Movable  kidney  of  varying  degrees 
can  be  readily  appreciated,  and  this,  taken  in  connection  with  the  splashing 
sound  found  below  the  normal  position  of  the  lower  border  of  the  stomach, 
is  pathognomic  of  gastroptosis.  The  corde  oblique  transverse  is  generally 
found  to  be  the  pancreas,  which  may  also  prolapse. 

Splashing  Sound. — This  is  the  best  method  to  determine  the  lower 
border  of  the  stomach  and  has  been  thoroughly  described. 

If  no  splash  can  be  originally  detected,  create  it  artificially  by  giving 
water,  or,  if  required,  add  a  little  Vichy,  or  tartaric  acid  and  sodium  bi- 
carbonate. 

Inflation  of  the  stomach  with  air  or  CO2  will  settle  doubtful  cases,  as 
the  upper  border  is  then  to  be  seen  on  inspection,  and  percussion  is  an  aid. 

Gastrodiaphany  is  an  accurate  method,  but  usually  unnecessary. 

Percussion. — There  is  at  times  dulness  or  flatness  in  the  epigastrium 
when  the  stomach  is  markedly  depressed,  the  liver  descending  in  such 
cases.  It  is  difiicult  to  differentiate  by  simple  percussion  unless  CO2  dis- 
tention has  also  been  employed.     The  scratch  method  is  of  assistance. 

Gastric  Secretion. — Examination  of  the  Gastric  Contents. — Ewald's  test- 
breakfast  should  be  employed  and  gastric  analysis  made  in  every  -case. 
Hyperchlorhydria,  hypochlorhydria,  achlorhydria,  or,  more  rarely,  achylia 
gastrica  (functional)  may  be  present.  Rarely  the  secretion  is  normal,  and 
then  usually  in  the  cases  found  accidentally,  presenting  no  symptoms. 

I  agree  with  George  R.  Lockwood  to  this  extent,  that  in  many  cases 
no  evidences  of  fermentation  can  be  found  on  test,  and  the  gas  also  may 
be  odorless.  In  hysteric  women  some  of  the  air  is  swallowed.  On  the 
other  hand,  in  some  patients  with  associated  marked  dilatation  (the  latter 
probably  being  primary),  such  as  I  have  seen  among  the  nervous  and 
insane  at  the  Manhattan  State  Hospital,  marked  fermentation  has  been 
found. 

The  treatment  is  modified  by  the  gastric  findings.  It  is  evident,  in 
some  cases,  that  the  secretory  conditions  are  influenced  by  the  misplace- 
39 


45° 


DISEASES    OF   THE    STOMACH    AISTD   INTESTINES 


ment,  since  Graham-Rogers,  at  the  Ward's  Island  Clinic,  found  that  in 
four  out  of  seven  cases  (six  of  hyperchlorhydria  and  one  of  hypochlor- 
hydria)  improvement  followed  the  use  of  Rose's  belt^  alone,  without 
medication  or  special  diet. 

Motor  Functions. — Motor  insufBciency^  is  undoubtedly  present  in 
some  cases.  This  is  particularly  true  in  the  water-trap  or  fish-hook  type 
of  gastroptosis.  On  the  other  hand,  many  cases  exist  with  few  or  any 
gastric  symptoms,  and  though  there  is  relaxation  of  the  musculature  of 
the  stomach,  compensation  takes  place  probably  by  relaxation  of  the  py- 


Fig.  217. — Slight  gastroptosis. 


Fig.  218. — Gastroptosis. 


loric  ring,  so  that  the  contents  of  the  stomach  enter  the  intestine  within 
the  normal  limit  of  time.  Per  contra  on  some  occasions,  or  from  some 
cause,  this  compensation  may  fail  and  then  symptoms  develop.  Motor 
functions  appear  only  slightly  diminished  in  other  cases,  or  even  normal,  as 
just  explained. 

This  is  the  probable  explanation  for  those  cases  which  have  existed  for 
years  without  symptoms  and  in  whom  they  suddenly  develop. 

Stomach  and  Small  Intestine. — Gastroptosis  may  occur  in  various 
forms  and  degrees,  semi-oblique  of  different  degrees,  looped,  or,  more  rarely, 
crescentic,  and  even  the  vertical  stomach  (Figs.  217-221).  In  some  cases 
we  may  have  primary  dilatation  and  then  ptosis.  These  illustrations 
represent  gastrodiaphany  of  various  cases.  Radiographs  will  be  given 
shortly. 


'  Rose  and  Kemp,  Atonia  Gastrica,  p.  124. 
^  Ibid.,  p.  79. 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD's   DISEASE  451 

Mainert  and  Holzknecht^  point  out  that  gastroptosis  is  always  ac- 
companied by  lengthening  of  the  stomach.     Bonninger  holds  that  the 


Fig.  219. — Vertical  stomach. 


Fig.  220. — Vertical  stomach  (extreme). 


lengthening  can  be  demonstrated  by  the  a;-rays  and  is  brought  about  by 
a  longitudinal  growth  of  the  body. 

As  far  as  I  can  determine,  from  physical  examination,  post-mortem, 


Fig.  221. — Crescentic  form  of  gastroptosis. 

and  operative  cases,  especially  in  the  marked  semi-oblique  or  particularly 
in  the  vertical  stomach,  there  seems  to  be  a  straightening  of  the  pyloric  curve 
and  some  dilatation  of  the  pyloric  end  and  of  the  duodenum,  probably  with 

1  Med.  Press  and  Circular,  Feb.  23,  1910. 


452 


DISEASES    OF    THE    STOMACH    AND  "INTESTINES 


relaxation  of  the  pylorus.  The  supports  of  the  duodenum  are  relaxed  and 
it  crosses  the  spine  at  a  lower  level.  I  believe  there  is  some  relaxation 
with  descent  of  the  pancreas,  and  also  relaxation  of  the  mesentery  and 
descent  of  the  rest  of  the  small  intestine. 


1 


I 


SESIOBE       III 
SrOMtC  H 


HOURS        AFTER       BIMOTII       MEIlL 


Fig.  222.  Fig.  223. 

Fig.  222.  — Gastroptosis.     Stomach  very  low  -}-  S. 

Fig.  223. — Residuum  six  hours  later  with  indentations  in  organ  from  adhesions. 
Enteroptosis  marked.  Agglutinated  mass  of  intestine  in  pelvis.  Bismuth  enema  not 
■yet  given. 


6    HOUSS     HFTEB    BISIHUTIl    « U  4  IKKEBI  UEl  Y 
ItFTER    BISK  DTK      ENEM  k 


Fig.  224. — Enteroptosis  marked  with 
adhesions  at  S,  a  six-hour  residuum  in 
stomach. 


Fig.  225. — Agglutinated  mass  of  in- 
testine in   pelvis.     Same  case  as  Fig. 

224. 


The  duodenal  distention  in  some  cases  is  to  be  expected  from  gravita- 
tion of  the  stomach  contents,  and  as  there  is  relaxation  of  the  mesentery 
I  beheve  the  so-called  "chronic  mesenteric  traction"  with  dilatation  of 


GASTROPTOSIS ENTEROPTOSIS GL^NARD's  DISEASE     453 

the  duodenum  as  a  result,  producing  symptoms  does  not  occur  very 
frequently. 

Gastroptosis  should  favor  acute  dilatation  of  the  stomach,  on  the 
mesenteric  traction  theory,  but  I  have  never  seen  such  a  condition  asso- 
ciated with  acute  ectasy. 

The  questions  of  the  relative  motility  of  the  different  types  of  ptosed 
stomachs  with  duodenal  distention  (dilatation)  with  enteroptosis  and  gas- 
troptosis and  the  motility  of  the  small  and  large  intestines  are  all  of  great 
interest  in  this  connection.     One  may  have  various  shaped  normal  stom- 


Fig.  226. — Vertical     stomach.     Slight    descent.     Slightly    cow-horn.     Found    empty 
in  six  hours.     Moderate  enteroptosis  found  with  this  case. 

achs — the  text-book,  fish-hook,  water-trap  and  cow-horn  as  described  by 
Cole.  I  believe  that  the  fish-hook  and  water- trap  type  of  stomach  are 
more  likely,  from  their  conformation,  to  become  atonic  and  retain  their 
contents  and  proportionally  more  readily  prolapse.  The  degree  of  duo- 
denal prolapse  occurring  with  enteroptosis  has  undoubtedly  a  bearing. 
Fortunately  nature  is  usually  an  excellent  compensator  and  though  the 
stomach  may  in  some  cases  empty  rapidly  and  somewhat  distend  the 
duodenum  (one  explanation  of  this  condition),  yet  rapid  peristalsis  of  the 
small  intestine  and  the  presence  of  liquid  contents  overcome  the  obstacle. 
One  must  remember  two  characteristics  of  the  small  intestines,  first,  rapid 
motility  and  second  that  quite  marked  stenosis  of  the  small  intestine,  more 


454  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

in  proportion  than  can  occur  in  the  large  intestine,  is  necessary  before  the 
liquid  contents  are  interfered  with  in  their  passage.  With  the  fish-hook  and 
water-trap  type  of  stomach  the  writer  has  noted  in  gastroptosis  cases,  the 
most  marked  bismuth  retention  after  six  hours.  He  has  seen  patients  with 
vomiting,  pain  suggestive  of  ulcer,  etc.,  rapidly  improve  and  the  symp- 
toms gradually  disappear  after  proper  abdominal  support  particularly 
Rose's  belt  has  been  supplied  and  correct  treatment  instituted.  The 
severe  types  of  drain-trap  stomach  the  stomach  with  long  pyloric  arm, 
described  by  Satterlee  and  LeWald  do  occur  and  may  very  rarely  re- 
quire suspension  operation,  but  the  writer's  experience  teaches  him  that 


Fig.  227. — Gastroptosis.     Deep  incisura  showing  active  motility  (cow-horn).     Found 

empty  in  six  hours. 

operation  is  usually  unnecessary.  It  is  remarkable  to  what  extent  the 
small  intestines  may  prolapse  and  yet  the  peristalsis  be  excellent,  in 
which  connection  radiograph  (Fig.  230)  is  worthy  of  notice.  Stasis 
seems  to  occur  most  frequently  in  the  colon,  where  normal  peristalsis  is 
slow  and  where  angulations  will  most  readily  interfere  with  the  passage  of 
solid  feces.  This  does  not  correspond  to  Lane's  theories.  Unquestion- 
ably kinks  and  adhesions  may  interfere  with  the  passage  of  contents  in 
.the  small  intestine,  but  they  must  be  fairly  severe  to  produce  interfer- 
ence with  fluid  contents.  In  radiographs  222-230  are  depicted  an  in- 
teresting series.     In  Fig.  231  is  a  severe  case  of  gastroptosis  of  drain- 


GASTROPTOSIS ENTEROPTOSIS GLfiNARD's    DISEASE 


455 


trap  type.  The  writer  during  a  lengthy  experience  has  treated  many 
cases  of  this  worst  type  of  gastroptosis  (water-trap)  with  vomiting  and 
retention  both  marked  and  has  secured  excellent  results — never  as  yet 
having  to  resort  to  surgical  procedure  (suspension).  In  a  few  cases  with 
adhesions,  these  have  been  freed,  but  no  suspensory  operation  was 
performed. 

Large  Intestine. — Enteropiosis. — The  degree  of  enteroptosis  varies  and 
there  seem  to  be  almost  numberless  types  with  many  varieties  of  angula- 
tions. Descent  of  the  transverse  colon  is  most  common  (Fig.  232);  it  can 
be  demonstrated  by  inflation  with  air  or  water,  or  with  bismuth  and 


Fig.  228. — Fish-hook,   stomach.     Vertical   gastroptosis.     Some   retention    was   shown 

at  the  end  of  six  hours. 


.v-rays,  and  they  help  in  differentiating  between  cases  of  redundant  sig- 
moid, transverse  colon  of  exaggerated  length,  and  displaced  and  angulated 
flexures  which  may  on  rare  occasions  require  special  operation.  Movable 
cecum  occurs  quite  frequently  with  enteroptosis  and  presents  at  times 
symptoms  suggestive  of  chronic  appendicitis.  Undoubtedly  there  may  also 
be  relaxation,  with  changes  in  the  position  of  the  sigmoid  (see  Fig.  233) 
or  even  of  the  descending  colon.  I  have  seen  a  case  of  this  type  recently. 
Nephroptosis. — It  seems  important  to  further  discuss  this  condition, 
though  I  have  already  described  many  of  its  features.  Movable  kidney 
from  traumatism  or  straining,  and  the  congenital  floating  kidney  with  a 


456 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


long  mesonephron,  constitute,  I  believe,  a  comparatively  small  percentage 
of  all  cases — in  my  own  opinion,  about  5  per  cent.;  while  Meynert  places 
them  at  10  per  cent.  The  balance  are  concomitants  of  enteroptosis 
(gastroptosis).     It  is  most  common  on  the  right  side. 

Einhom,  as  well  as  many  other  authors,  recognize  movable  kidney  as 
an  essential  symptom  of  enteroptosis. 

Nephroptosis  occurs  at  least  six  or  seven  times  more  frequently  in 
women  than  in  men. 

Nephroptosis  exists  in  about  15  per  cent,  of  all  women  examined,  as- 
sociated with  gastroptosis;  but  in  many  cases  no  symptoms  are  present. 


Fig.  2 29. ^Water-trap  stomach.     Gastroptosis  with  some  dilatation. 


No  worse  judgment  can  be  shown  than  to  tell  a  patient  that  she  has  a  movable 
kidney. 

Edebohls  finds  it  in  20  per  cent,  of  his  cases,  disregarding  associated 
ptoses,  and  some  even  place  it  at  33  per  cent. 

The  normal  kidney  is  slightly  movable  during  respiratory  movements. 
The  most  accurate  method  of  kidney  palpation!  have  already  described. 

Glenard  classifies  four  degrees  of  movable  kidney: 

First  Degree. — The  lower  pole  of  the  kidney  is  palpable  on  deep  inspira- 
tion and  slips  back  on  expiration.     It  cannot  be  arrested. 

Second  Degree. — The  body  of  the  kidney  can  be  palpated  and  arrested, 
but  not  the  upper  border. 


GASTROPTOSIS — ENTEROPTOSIS — GL^NARD's  DISEASE     457 

Third  Degree. — The  superior  border  of  the  kidney  can  be  palpated. 

Fourth  Degree. — The  entire  kidney  is  palpable  and  it  may  be  found  in 
various  regions  of  the  abdomen,  near  the  gall-bladder  or  as  low  as  the  ap- 
pendical  region. 

I  have  already  referred  to  the  various  symptoms  attributed  to  movable 
kidney,  such  as  dilatation  of  the  stomach  due  to  pressure  on  the  duodenum; 
jaundice;  gall-stone  symptoms  or  stasis  with  the  production  of  stone; 


Fig.  230. — (Same  case  as  229.)  Six  hours  after  bismuth  meal.  Residuum  in  stomach. 
Note  that  the  small  intestines  have  rapidly  emptied,  showing  excellent  motility.  Note 
furthermore  the  bismuth  has  passed  rapidly  into  the  large  intestine  as  far  as  the  splenic 
flexure.  The  entire  colon  is  markedly  ptosed.  Constipation  marked.  This  patient 
suffered  chiefly  from  nervous  symptoms,  headaches,  mental  depression,  poor  memory. 
Hyperacidity  moderate.    Evidently  stasis  not  present  in  small  intestines. 

gastro-intestinal  and  pelvic  disturbances;  chronic  appendicitis  as  a  result 
of  congestion  from  compression  of  the  superior  mesenteric  vein  against  the 
pancreas  and  spine  (in  20  per  cent,  of  cases,  according  to  Edebohls). 

All  these  symptoms  are  referable  to  splanchnoptosis. 

Goelet  believes  that  in  75  per  cent,  of  nephroptosis  of  the  third  degree, 
or  beyond,  there  is  a  pyelonephritis  or  interstitial  nephritis. 

In  20  cases  of  nephroptosis  of  the  third  degree  or  more  (with  entero- 
ptosis)  at  the  Manhattan  State  Hospital,  I  requested  LeRoy  Broun  to 
examine  the  gynecologic  conditions,  and  in  no  case  could' any  connection 
be  found  between  the  prolapsed  kidney  and  the  genital  organs.     The  late 


458 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Ferd  C.  Valentine^  and  Terry  M.  Townsend,  as  a  check,  made  special 
examinations  of  the  genito-urinary  tract  and  urine,  but  found  no  evidence 
of  nephritis  or  pyelonephritis  in  these  20  cases. 

Such  examinations  should  not  be  made  immediately  after  palpation, 
as  Menge  demonstrated  that  albuminuria  appeared  directly  thereafter. 

Schreiber^  showed  this  in  39  out  of  42  cases  examined  within  ten  to 
fifteen  minutes  after  palpation,  and  that  it  sometimes  lasted  hours.  Renal 
epithelium,  red  and  white  cells,  but  no  casts  were  found.     He  believes  it 


DNFMATOGl 

■1 

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Pf?ONE  IMMEDIATELY  AFTER   BARIUM  MEAL 
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Fig.  231. — Gastroptosis  (drain- trap  type)  with  tubular  ascending  duodenum  at 
+.  Type  with  motor  insufficiency  and  vomiting.  Treated  by  Rose's  belt,  diet  and 
medication;  forced  feeding.     No  operation.     Author's  case  of  severe  type. 

will  furnish  a  method  of  differential  diagnosis,  as  if,  on  palpation  of  a  doubt- 
ful mass,  this  condition  occurs,  it  will  prove  to  be  kidney.  Of  course, 
nephritis  or  pyelonephritis  may  occur  in  some  cases;  and  after  differential 
ureteral  catheterization,  if  both  kidneys  are  prolapsed,  nephropexy  is 
indicated  in  the  diseased  prolapsed  organ. 

Hydronephrosis,  or  adhesion  of  the  kidney  to  the  appendix  or  gall- 
bladder, may  also  occur  occasionally. 

In  some  cases  more  marked  or  severe  symptoms  may  be  attributed  to 
the  movable  kidney: 

1  Kemp,  Amer.  Jour,  of  Urology,  Jan.,  1906 
^  Zeitschrift  fur  klin.  Med.,  vol.  Iv,  No.  3. 


GASTROPTOSIS — ENTEROPTOSIS GLENARD  S    DISEASE 


459 


(i)  There  may  be  a  weight  or  special  feehng  of  traction  on  that  side, 
increased  on  standing  or  walking,  and  lessened  in  the  recumbent  posture. 

(2)  The  kidney  may  be  increased  in  size,  tender  on  pressure,  and  there 
may  be  pain  and  tenderness  in  the  lumbar  region,  frequent  urination,  and 
burning  headache. 

(3)  Dietl's  crisis,  probably  due  to  torsion  of  the  pedicle,  will  produce 
severe  abdominal  pain,  chills,  nausea,  vomiting,  fever,  and  even  collapse. 
The  urine  may  be  high  colored  and  blood  be  present.  Abdominal  support 
should  first  be  tried  systematically  in  these  conditions  before  operation 
is  advocated. 

Floating  Liver  (Movable  Liver). — Osier  claims  that  on  a  considerable 
number  of  cases  there  is  a  mistaken  diagnosis.  One  anomaly  is  the  tilting 
forward  of  the  organ,  so  that  the  anteroposterior  axis  becomes  vertical 


Enteroptosis. 


and  not  horizontal,  and  a  considerable  part  of  the  surface  of  the  right  lobe 
is  in  contact  with  the  abdominal  wall. 

In  one  type  of  lacing  liver,  the  anterior  part  of  the  right  lobe  is  greatly 
prolonged,  a  shallow  transverse  groove  separating  it  from  the  rest  of  the 
organ. 

A  slight  grade  of  mobility  (floating  liver)  is  found  in  enteroptosis,  but 
the  cases  reported  are  comparatively  few. 

In  some  cases  the  upper  surface  may  lie  below  the  costal  margin. 
G.  E.  Graham  has  collected  70  cases.     The  condition  is  rare  in  men. 

In  some  cases  of  enteroptosis  with  hepatoptosis,  the  symptoms  may  be 
fairly  marked  in  the  liver,  there  being  pains  in  the  hepatic  region  radi- 
ating toward  the  back  and  at  times  of  a  tearing  character.  There  may 
be  some  local  tenderness  and  attacks  similar  to  hepatic  colic,  though 
usually  no  jaundice. 

Einhorn'  described  several  groups  of  cases,  dyspeptic  asthma  among 
^  Med.  Rec.,  Sept.  16,  1894. 


460 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


them,  but  from  my  own  point  of  view  this  condition  seems  to  be  a  part  and 
parcel  of  the  general  syndrome  "enteroptosis,"  with  marked  local  symp- 
toms, such  as  pain  or  colic,  in  some  cases.  In  extreme  cases  the  liver  may 
drop  down  so  that  the  upper  surface  is  below  the  costal  margin. 

Gall-bladder. — In  cases  of  marked  gastroptosis,  gall-bladder  symp- 
toms simulating  biliary  colic  at  times  occur.  With  the  descent  of  the 
stomach  and  associated  torsion,  or  descent  of  the  duodenum,  there  is 
probably  interference  witlj  the  passage  of  the  bile.  It  is  interesting  to 
note  that  after  proper  abdominal  support  of  the  prolapsed  organs,  the 


Fig.  233. — Ptosis  of  sigmoid  flejcure. 

symptoms  of  gall-stone  colic  will  disappear.  E.  Gallant  reports  a  number 
of  cases. 

Cardioptosis. — In  my  own  experience,  ptosis  of  the  heart  is  present 
only  in  marked  cases  of  splanchnoptosis,  especially  where  there  is  skeletal 
deformity.  Einhorn  finds  it  associated  with  floating  liver.  The  latter 
is  more  frequently  a  concomitant  of  skeletal  deformity,  I  believe,  and 
hence  the  two  conditions  are  associated. 

Movable  Spleen. — Movable  spleen  may  occur  from  below  the  rib  even 
into  the  pelvis.  There  may  be  dragging  pains  in  the  side,  torsion  of  the 
pedicle,  swelling  of  the  organ,  with  pain  and  fever  associated. 

Diagnosis. — Curiously  enough,  the  majority  of  writers  pay  chief  at- 
tention to  nephroptosis,  refer  to  the  stomach  as  dilated  (a  result  of  kidney 


GASTROPTOSIS — ENTEROPTOSIS — GLENARD's   DISEASE  46 1 

pressure),  and  do  not  differentiate  between  gastroptosis  and  dilatation  of 
the  stomach.  It  is  the  position  of  the  upper  border  which  determines 
ptosis,  but  the  following  symptoms  will  usually  settle  the  diagnosis.  The 
peculiar  conformation  of  the  abdomen  heretofore  described,  the  separa- 
tion of  the  recti,  movable  kidney,  and  the  determination  that  the  lower  border 
of  the  stomach  is  abnormally  low,  are  sufficiently  diagnostic  of  gastroptosis. 

Inflation  or  gastrodiaphany  may  be  used  in  disputed  cases  to  settle 
the  question.     The  x-rays  are  also  of  great  value  for  this  purpose. 

Glenard's  "Belt  Test."— If  one  stand  behind  the  patient  and,  en- 
circling him  with  the  arms,  lift  up  and  support  the  lower  protuberant  ab- 
domen, and  this  gives  relief,  it  suggests  enteroptosis. 

X-rays. — The  diagnosis  of  gastroptosis  can  be  made  without  the  use  of 
the  a:-rays.  I  prefer  their  employment  as  one  secures  an  excellent  idea  as 
to  existing  conditions,  can  diagnose  angulations  and  adhesions  if  present, 
and  can  give  an  exact  prognosis.  The  patient  is  convinced  as  to  the  cor- 
rectness of  the  diagnosis  and  the  necessity  of  following  the  treatment. 
Radiographs  of  the  stomach  directly  after  the  bismuth  meal  and  six 
hours  later;  also  after  a  bismuth  enema  with  the  patient  standing  should 
be  taken.  Healy's  method  should  then  be  employed,  i.e.,  the  patient 
placed  five  minutes  in  the  knee-chest  position,  then  turned  over  and  radio- 
graphed in  the  Trendelenburg  posture  or  Tousey's  modification,  the  belly 
Trendelenburg.  This  determines  the  mobility  of  the  intestines  and  the 
degree  and  location  of  adhesions  if  present. 

P*rognosis. — The  cases  of  congenital  type  with  funnel  thorax  or  other 
skeletal  deformities  are  the  most  unfavorable  to  treat;  but  even  in  these 
much  can  be  done. 

The  acquired  tj^pe  presents  a  favorable  prognosis  as  to  absolute  cure, 
though  some  tend  to  relapse  if  continuous  care,  as  to  regulation  of  mode  of 
life,  exercise,  and  diet,  is  not  kept  up.  I  have  seen  a  number  of  cures,  as 
has  every  other  observer. 

Treatment. — Prophylaxis. — Much  can  be  done  to  prevent  the  acquired 
type  of  gastroptosis.  Improperly  made  corsets  compress  the  thorax  or 
waist.  Tight  lacing  and  the  use  of  tight  bands  around  the  waist  are 
productive  of  ptosis.     These  should  be  avoided. 

In  my  opinion,  most  of  the  Landau  (postpartum)  cases  of  splanch- 
noptosis are  absolutely  preventable,  the  fault  frequently  being  due  to  the 
physician  in  attendance,  the  patient's  abdomen  not  being  properly  sup- 
ported, and  she  also  being  allowed  to  leave  the  bed  too  soon.  There  is 
a  marked  thinning  and  weakening  of  the  abdominal  wall  during  pregnancy, 
and  after  delivery  immediate  attention  should  be  given  to  its  support. 

For  several  years  Douglas  H.  Stewart,  of  New  York,  has  been  employ- 
ing as  a  routine  postpartum  method  of  support  (at  my  suggestion)  Rose's 
plaster  strapping,  reinforcing  it  with  lateral  soft-rubber  strips  (an  idea 
of  his  own;.  He  states  that  it  supports  the  organs  perfectly,  prevents 
abdominal  relaxation,  and  enables  the  patient  to  sit  up  in  bed  earlier,  with 
resulting  improved  drainage  of  the  uterus,  and  to  be  about  at  an  earlier 
period. 

Bassler^  treats  of  the  necessity  of  abdominal  support  after  confinement, 

1  Prophylactic  Measures  Against  the  Development  of  Landau  Cases  of  Visce- 
roptosis, Therapeutic  Gazette,  Sept.  15,  1907. 


462  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

and  describes  methods  of  strengthening  the  abdominal  muscles  and  the 
value  of  forced  feeding. 

Treatment  of  Existing  Gastroptosis  (Splanchnoptosis). ^There  are 
three  chief  principles  involved: 

(i)  The  support  and  strengthening  of  the  abdominal  muscles,  which 
also  increase  intra-abdominal  pressure. 

(2)  The  increase  of  intra-abdominal  pressure,  by  reducing  the  volume 
of  the  abdominal  cavity  through  accumulation  of  fat,  and  thus  lifting  up 
the  stomach. 

(3)  Correction  of  the  gastro-intestinal  disturbances  and  the  toning  up 
of  the  nervous  system. 

(i)  Abdominal  Support. — The  selection  of  a  proper  apparatus  for 
mechanical  support  to  the  abdominal  muscles,  which  at  the  same  time 
will  increase  intra-abdominal  tension,  is  the  first  indication, 

I  have  employed,  by  preference  for  some  time  past,  adhesive  plaster 
strapping  in  the  form  of  the  belt  devised  first  by  Achilles  Rose.  I  have 
already  referred  to  the  superiority  of  moleskin,  first  suggested  in  this  coun- 
try by  me  after  numerous  experiments.  The  Z.  O.  type  should  be  used 
by  the  method  already  described.     The  support  afforded  is  continuous, 


Fig.  234. — The  proper  way  of  adjusting  the  corset  (after  Gallant). 

should  never  be  kept  on  over  three  to  five  weeks,  and  on  signs  of  loosening, 
a  new  belt  should  be  applied;  the  patient,  between  belts,  taking  a  full 
bath  and  employing  talcum  powder  over  the  surface  during  the  twelve 
to  twenty-four  hours'  intermission.  My  longest  case  wore  the  belt  four- 
teen months,  winter  and  summer,  it  being  reapplied  every  four  to  six  weeks, 
with  a  gain  of  44  pounds  and  perfect  cure. 

Some  of  the  other  types  of  adhesive  strapping  belts  may  be  employed 
if  the  wide  plaster  necessary  for  Rose's  belt  cannot  be  procured.  Pressure 
is  exerted  by  the  belt,  from  the  symphysis  to  the  umbilicus  in  front,  the 
intestines  are  forced  up,  and  hence  the  stomach;  and  the  increased  pressure 
aids  in  holding  back  the  kidneys. 

Next  in  value  to  adhesive  plaster  is  the  Gallant  corset,  which  also 
exercises  upward  pressure  and  support  below,  and  is  loose  above.  The 
method  of  its  application  is  shown  in  Fig.  234. 

The  La  Grecque  corset  (Van  Orden's),  recently  devised,  is  an  excellent 
appliance.  It  well  supports  the  spine  and  pelvis,  is  made  in  a  single  piece 
behind,  and  is  subdivided  in  front,  as  in  Fig.  235,  A.  In  Fig.  235 j  B,  is 
shown  the  corset  after  application.     It  should  be  applied  in  the  dorsal 


GASTROPTOSIS ENTEROPTOSIS GLENARD  S    DISEASE 


463 


position,  like  the  Gallant  corset.  The  pressure  is  exerted  like  Rose's 
belt,  from  the  symphysis  to  the  umbilicus,  and  it  is  loose  about  the  thorax 
and  upper  abdomen.  Of  late  I  use  the  adhesive  strapping  for  several 
months  and  then  follow  it  with  the  Van  Orden  corset.  The  indications 
are  the  same  as  for  Rose's  plaster.  In  Figs.  236  and  237  is  demonstrated 
by  .T-rays  the  stomach  and  colon  before  and  after  the  application  of  the 
corset.     The  raise  was  only  slight — i  inch  in  this  case. 

If  the  patient  will  not  consent  to  these  methods,  the  silk  abdominal 
bandages,,  as  previously  illustrated,  are  useful.  In  male  cases  Rose's 
belt  and,  later,  the  silk  belt  are  indicated.  Lane's  leather  abdominal  sup- 
port is  excellent. 


A  B 

Fig.  2  35.^La  Grecque  corset:  A,  Lower  segment  of  corset;  B,  corset  after  adjustment. 

Supports  formed  with  pads  for  special  organs  are  unscientific. 

Kilmer's  belt,  drawn  snug  below  and  lax  above,  or  the  Van  Valzah- 
Hayes  belt  can  be  employed. 

Exercise. — Massage. — Gymnastics. — There  are  marked  inconsistencies 
in  many  of  the  recommendations  as  to  active  exercises,  flexion,  and  ex- 
tension of  the  body  by  elevation  of  the  legs,  gymnastics,  etc.,  to  strengthen 
the  abdominal  muscles.  There  is  no  better  way  to  take  off  abdominal 
fat  and  to  reduce  omental  fat  than  by  these  means;  and  in  the  cases  with 
marked  weight  reduction  it  is  impossible  to  put  on  fat  if  excessive  exercises 
are  employed. ^ 

In  moderation  and  properly  directed,  they  are  of  service  later  when  the 

weight  has  been  increased.     Driving  or  moderate  walks  in  some  cases  are 

useful. 

^  In  the  cases  of  ptosis  due  to  excessive  fat  production,  with  relaxed  muscles,  active 
exercise  combined  with  abdominal  support  are  indicated. 


464 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


Massage. — On  the  other  hand,  gentle  abdominal  massage  and  often 
general  massage  of  mild  type,  taken  several  times  a  week,  will  improve  the 
muscular  tone.  The  use  of  light  cannon-ball  massage  of  the  abdomen, 
taken  five  minutes  once  or  twice  a  day,  or  mild  vibratory  massage,  at 
home  in  bed,  with  a  good  vibrator,  I  have  found  of  service. 

In  the  severe  type  of  case,  absolute  rest  in  bed  for  three  to  six  weeks 
with  the  Rose's  belt  applied,  forced  feeding,  and  mild  massage,  etc.,  give 
the  best  results;  and  if  the  patient  is  very  much  prostrated  I  omit  massage 
at  first. 

2.  Increase  of  Abdominal  Pressure  through  Diet  by  Fat  Accumulation. — 
Diet. — There  are  certain  general  principles  we  must  follow: 


Fig.  236. — Without  corset.     (Courte>>-  of  \  an  Orden  Co.) 


If  there  is  hyperchlorhydria,  plenty  of  albuminous  foods  and  fats  (the 
calories  being  made  up  by  butter  and  cream),  should  be  given.  Diminish 
starchy  foods,  order  frequent  feedings,  avoid  acids,  spices,  and  alcohol. 
Often  alkalis  are  required. 

If  h)T)ochlorhydria  or  achylia,  little  meat  and  abundance  of  carbohy- 
drates and  fats,  with  dilute  hydrochloric  acid,  stomachics,  etc. 

Not  more  than  8  ounces  (250  c.c.)  of  fluid  should  be  taken  at  a  time 
and  thorough  mastication  of  the  food  should  be  enjoined.  If  the  case  is 
not  confined  to  bed,  a  rest  of  fifteen  to  thirty  minutes  after  each  meal,  if 
possible,  is  advisable.  The  patient  should  take  the  three  chief  meals 
daily  at — 


8.CX3  A.  M.,  "I 

1. 00  P.  M.,  \  with  intermediate  feedings  at 

6.30  p.  M.,  J 


10.30  A.  M., 
3.30  P.  M., 

and  often  at 
9.30  p.  M. 


GASTROPTOSIS ENTEROPTOSIS GLENARD'S    DISEASE  465 

John  Russell's  method,  as  employed  in  tuberculosis,  is  of  value  in  some 
cases.  The  foods  especially  of  use  to  increase  weight  and  which  can  be 
employed  for  the  interval  feedings  are: 

Milk,  raw  eggs,  i  ounce  (30  c.c.)  cream  in  8  ounces  (250  c.c.)  milk, 
koumiss,  matzoon,  bacillac,  lactone-buttermilk  and  crackers  or  bread 
with  plenty  of  butter.     I  have  given  butter  up  to,  half-pound  and  cream 
Sviii  daily  in  addition  to  the  other  food. 

Raw  eggs  can  be  given,  beaten  up  in  milk.  It  is  well  to  start  with  one 
or  two  daily,  and  increase  gradually  to  six  or  eight  per  day.  They  possess 
considerable  value.  One  could  give,  for  example,  at  the  intermediate 
feedings: 

10.30  A.  M. — Milk,  gviij  (250  c.c),  with  2  raw  eggs. 
3.30  p.  M. — Koumiss,  5viij  (250  c.c). 

9.30  P.  M. — Same  as  at  3.30  P.  M.,  or  milk  with  cream,  and  vary  the 
methods. 


Fig.  237. — With  corset.     (Courtesy  of  Van  Orden  Co.) 

Two  soft-boiled  eggs  can  be  given  for  breakfast. 

Green  vegetables  and  raw  or  cooked  fruits  should  be  given  for  constipa- 
tion, depending  on  the  gastric  conditions.  Strict  attention  to  the  bowels 
is  imperative. 

I  have  seen  the  stomach  elevated  t,  or  4.  inches  by  the  increase  of  fat.  ^ 

Electricity. — In  the  ambulant  cases,  the  use  of  static  electricity  will 
prove  of  service  with  some  patients  to  improve  the  general  muscular  tone, 
or  it  may  be  employed  after  the  rest  cure  has  been  completed.  The  ex- 
ternal application  of  galvanic  or  faradic  electricity  I  have  used  with  good 
results  in  some  cases,  but  I  never  remove  the  belt. 

Intragastric  faradization  has  been  recommended  to  improve  the  atony 
of  the  stomach,  and  galvanization  for  the  pain.     I  have  had  patients 

^  On  the  other  hand,  fat  reduction  is  indicated  in  the  rare  cases  of  adipose  with 
gastroptosis.    The  method  is  described  under  "Obesity." 

30 


466  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

bitterly  complain  of  the  intragastric  method;  one  case  notably  had  been 
treated  thus  systematically,  with  increasing  nervous  symptoms  being  pro- 
duced and  marked  nausea,  stating  she  was  worse  after  each  treatment. 
The  simple  method  of  external  application  seems  to  me  advisable  in  those 
cases. 

Massage  of  the  Kidney. — Several  methods  have  been  recommended  for 
treatment  of  the  painful  movable  kidney. 

The  operator,  sitting  on  the  side  of  the  kidney  to  be  massaged,  places 
the  left  hand  (if  it  is  the  right  kidney)  on  the  lumbar  region,  so  that  the 
organ  rests  on  the  finger,  the  thumb  being  supported  by  the  ribs.  With 
the  finger-tips  of  the  right  hand  he  pushes  on  the  kidney  from  in  front  and 
gently  kneads  it. 

Brandt  places  the  patient  in  the  lithotomy  position,  and,  having  re- 
placed the  kidney,  places  both  hands  in  front  under  the  margin  of  the 
ribs,  and  makes  vibratory  movements  backward  and  upward,  allowing 
the  finger-tips  to  slip  around  to  the  back.  The  patient  aids  in  securing 
this  position  by  lifting  his  buttocks. 

As  palpation  alone  will  cause  albuminuria,  I  do  not  approve  of  these 
methods,  but  merely  refer  to  them.     It  is  sufficient  to  replace  the  kidney. 

Elevation  of  the  Foot  of  the  Bed. — This  method  may  be  employed  in 
those  cases  taking  the  rest  cure  who  do  not  wear  an  abdominal  support 
continuously.  Elevation  of  the  buttocks  may  be  substituted.  They  are 
unnecessary  when  Rose's  belt  is  employed. 

Iron  and  arsenic  are  indicated  in  all  cases,  such  as — 

Iron  tropon,  3j  (4-o),  t.i.d.;  or 

Fowler's  solution  of  arsenic,  TTliij  to  v  (0.177-0.296  c.c),  t.i.d.,  or  any 
good  combination  of  iron  and  arsenic. 

An  excellent  pill  is  Blaud's  iron,  5  grains  (0.3),  in  which  sodium  arsenate, 
Ho  to  Ho  grain  (0.00108-0.0021),  has  been  incorporated. 

If  no  hyperchlorhydria  is  present,  strychnin,  J^o  to  Ho  grain  (0.00108- 
0.0021),  can  be  included. 

Hyperacidity  should  be  treated  with  the  alkalis. 

Hypo-acidity  with  nux,  strychnin,  hydrochloric  acid,  and  stomachics. 

Bromid,  10  grains  (0.6),  or  veronal,  5  to  tH  grains  (0.33-0.5),  sulfonal, 
10  grains  (0.6),  or  trional,  10  grains  (0.6),  are  valuable  for  sleeplessness, 
given  an  hour  before  retiring.     Midonal,  5  grains  (0.3),  is  useful. 

Hydrotherapy. — The  Scotch  douche,  one  to  two  minutes  over  the  ab- 
domen, in  convalescent  cases  has  rendered  service. 

The  patients  with  much  adipose,  with  relaxed  abdominal  muscles 
and  gastroptosis  require  different  treatment;  a  silk  supporting  belt  for 
the  abdomen,  weight  reduction  by  diet  and  active  exercise,  and  par- 
ticularly strengthening  of  the  abdominal  muscles  by  flexion  and  exten- 
sion movements  of .  the  abdomen.  One  sees  the  type  occasionally  to 
which  I  refer  under  Etiology. 

The  Priessnitz  compress  aids  to  relieve  pain. 

A  glass  of  cold  water,  Vichy  or  Carlsbad,  on  rising  helps  the  bowel 
action, 

DietVs  Crisis. — Apply  heat  to  the  kidney;  employ  fluid  diet;  elevate 
the  food  of  the  bed;  replace  the  kidney. 


GASTROPTOSIS ENTEROPTOSIS— GLENARD'S    DISEASE  467 

Codein,  K  to  }-^  grain  (0.016-0.022),  or  morphin,  ^  to  3.^  grain  (0.008- 
0.016),  may  be  required,  by  hypodermic. 

Constipation. — Olive  oil  enemata;  cascara;  compound  rhubarb,  purgen, 
and  regulin,^  if  required,  are  excellent.  Russian  mineral  oil  or  American 
mineral  oil,  5  ss  a.  m.  and  p.  m.  is  my  favorite  remedy. 

Complications,  such  as  mucous  colic  or  catarrhal  colitis,  must  be  ap- 
propriately treated. 

Surgery. — In  splanchnoptosis,  if  all  medical  treatment  after  a  year 
conscientiously  applied  prove  a  failure,  suture  of  the  recti  (abdominis)  and 
thus  tightening  of  the  abdomen,  as  advocated  by  Robert  T.  Morris  and 
by  Charles  Codman,^  is  the  most  scientific  procedure. 


c 


Fig.  238. — Beyea's  operation;  suture  of  the  gastrohepatic  omentum  to  secure 
elevation  of  the  stomach  in  gastroptosis.  The  first  layer  of  sutures  completed,  the 
second  and  third  being  introduced  (Moynihan). 

If  there  are  nephritis,  pyelonephritis,  or  intermittent  hydronephrosis 
confined  to  the  prolapsed  kidney,  then  nephropexy  is  indicated.  After 
repeated  attacks  of  Dietl's  crisis,  when  medical  measures  afiford  no  relief, 
nephropexy  may  be  advised. 

Hydronephrosis  or  pyelonephritis  may  be  of  such  a  character  as  to 
require  nephrectomy. 

Operations  on  individual  organs  except,  as  noted  below,  /  am  opposed 
to  unless  there  be  marked  gastric  dilatation  with  the  ptosis,  and  a  year's 
treatment  affords  no  relief. 

Occasionally  a  redundant  sigmoid  may  require  sigmoidopexy,  or  it 
may  be  necessary  to  hitch  up  an  angulated  colon  or  a  ptosed  cecum. 
Shortening  of  the  lesser  omentum  (plication),  and  thus  elevating  the 

^  See  under  Constipation  for  other  remedies. 
^  Med.  Rec,  Oct.  19,  1907. 


468  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

stomach,  as  devised  by  Beyea^  is  depicted  in  Fig.  238.  When  these 
sutures  are  drawn  and  tied,  the  stomach  is  elevated  into  its  normal 
position. 

Gastroplication,  shortening  of  the  lesser  omentum,  attaching  the  lesser 
curve  of  the  stomach  to  the  abdominal  wall,  suture  of  the  transverse  colon 
to  the  abdominal  wall,  sewing  the  greater  omentum  to  the  abdominal 
wall,  have  all  been  recommended. 

Gastro-enterostomy  may  be  indicated  in  gastroptosis  with  ectasia  and 
marked  fermentation  which  does  not  respond  to  medical  treatment.  The 
spleen  has  been  stitched  up,  or  removed  if  inflamed. 

Duodeno-enter ostomy  has  been  advocated  by  Byron  Robinson,  but  I 
see  no  indication  for  it. 

Elliot^  recommends  anchoring  the  liver  in  hepatoptosis. 

In  rare  cases,  gastroplication,  with  shortening  of  the  lesser  omentum; 
or  the  latter,  with  gastro-enterostomy,  might  be  necessary. 

Author^ s  Experience  with  Surgery. — In  many  of  these  cases  of  Gle- 
nard's  disease,  veils  or  adhesions  are  present.  As  a  rule  I  do  not  advocate 
operation  upon  these,  unless  persistent  constipation  (intestinal  stasis  of 
an  obstinate  character)  continues  and  medical  treatment  with  the  use  of 
forced  feeding  and  proper  mechanical  support  fails  to  afford  relief  after 
a  reasonable  trial  of  six  months.  In  such  event,  separation  of  adhesions 
or  veils,  I  have  had  performed  in  several  cases.  Quite  frequently  tender- 
ness at  McBurney's  point  is  in  evidence,  a  sHght  appendical  catarrh 
secondary  to  the  enteroptosis,  particularly  when  mobility  and  misplace- 
ment of  the  cecum,  with  resulting  intestinal  stasis,  are  present.  I  have 
seen  a  number  of  these  cases  relieved  by  Rose's  belt  and  the  usual  treat- 
ment for  gastroptosis — all  the  symptoms  disappearing.  On  the  other 
hand,  if  medical  treatment  affords  no  relief,  after  several  months  trial, 
I  have  had  appendectomy  performed  and  simple  anchoring  of  the  cecum, 
with  excellent  results,  the  usual  mechanical  support  and  treatment  of  the 
enteroptosis  being  then  carried  out  to  a  successful  issue.  On  one  occa- 
sion, a  case  of  enteroptosis,  with  persistent  catarrhal  colitis,  and  marked 
prolapse  of  the  sigmoid,  as  medical  treatment  afforded  no  results;  the 
sigmoid  was  suspended  by  my  advice  with  cure  of  the  colitis.  General 
treatment  for  the  enteroptosis  was  continued  after  operation.  On  several 
occasions  I  have  had  bands  passing  to  the  ileum  (producing  the  ileal 
kink)  cut  by  the  surgeon,  when  the  constipation  could  not  be  relieved. 
On  one  occasion,  the  stomach  was  gastroplicated  and  suspended  with  bad 
results  (a  fatality).  Special  correction  of  complications,  as  herein  men- 
tioned may  occasionally  require  some  surgery  and  that  rarely.  For 
example  these  few  experiences  occurred  among  a  large  number  of  cases 
of  gastroptosis — not  less  than  500  in  number.  Suspension  of  the  stomach 
or  colon  (transverse)  should  rarely  be  required.  I  have  yet  to  see  a 
case  of  enteroptosis  that  required  the  dangerous  resection  operation,  in 
my  opinion. 

'  Jour.  Amer.  Med.  Assoc,  March  5,  1910. 
^  Med.  News,  Nov.  12,  1904. 


CHAPTER  XVII 
NERVOUS  AFFECTIONS  OF  THE  STOMACH 

Gastric  neuroses  may  be  defined  as  functional  disturbances  of  the 
stomach  without  any  discoverable  anatomic  basis,  there  being  no  organic 
lesion  of  the  organ. 

Etiology. — These  cases  have  either  inherited  a  nervous  constitution, 
or,  through  indiscretions,  have  brought  about  a  condition  of  nervous 
prostration.  Sometimes  the  gastric  disturbances  have  apparently  a  reflex 
origin,  depending  on  disturbances  in  remote  parts  of  the  body,  as  in  the 
sexual  organs,  appendix,  eyes,  etc.,  and  these  factors  must  always  be 
searched  for. 

For  example,  as  a  reflex  from  appendicitis,  we  may  have  hyperchlor- 
hydria  with  or  without  hypersecretion,  pylorospasmus,  hypochlorhydria, 
excessive  vomiting,  achlorhydria  hasmorrhagica  gastrica  (symptoms  of 
chronic  gastritis  accompanied  by  hemorrhage  apparently  from  erosions), 
and  apparently  symptoms  of  gastric  ulcer.  Graham^  and  Guthrie  cured 
89  out  of  115  patients  with  gastric  symptoms  by  appendectomy,  and  se- 
cured improvement  in  20  others. 

They  are  divided  into  sensory,  motor,  and  secretory  neuroses,  and  may 
appear  separately  or  in  combination.  They  occur  most  frequently  in 
women  from  puberty  to  menopause,  and  quite  frequently  at  these  special 
periods.  In  men  they  appear  most  often  during  middle  life  and  most 
frequently  in  the  higher  classes.  There  is  probably  a  predisposition  to  the 
condition.  Worry,  extreme  mental  exertion,  excesses,  and  excitement 
may  be  predisposing  factors.  Organic  lesions  of  the  stomach  must  be 
excluded. 

Classification. — Neurosis  of  the  stomach  may  present  the  appearance 
of  some  primary  disease,  or  may  be  one  of  the  symptoms  of  hysteria  or 
neurasthenia,  or  may  he  a  reflex  symptom  due  to  disease  of  some  other  organ. 
In  cases  of  this  last  description,  though  there  is  no  organic  change  in  the 
stomach  and  the  disturbance  in  this  organ  is  purely  reflex,  there  is  an  ana- 
tomic cause  elsewhere.  They  should,  strictly  speaking,  be  differentiated 
from  the  pure  gastric  neuroses,  since  treatment  of  a  distant  diseased  organ 
may  cure  an  apparently  pure  gastric  neurosis.  This  emphasizes  the  neces- 
sity of  thorough  examination.  Vagotonia,  or  sympatheticotonia,  or  the 
mixed  condition  may  be. responsible  for  cases  previously  believed  to  be 
gastric  neuroses.  See  the  section  on  these  conditions.  Pure  gastric 
neurosis  I  believe  rare. 

Peculiarities. — Generally  the  nervous  system  shows  more  or  less  devia- 
tion from  normal  conditions.  Leube  and  Boas  have  probably  best  de- 
scribed the  condition.  There  are  headache,  mental  depression,  lack  of 
energy;  at  times  fear,  palpitation,  dyspnea,  and  sweating.     On  the  other 

^  Jour.  Amer.  Med.  Assoc,  March  19,  1910,  p.  q6o. 
469 


47©  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

hand,,  there  may  be  excitement  and  sensitiveness.  There  are  an  increase 
or  diminution  of  reflexes,  local  hyperesthesia,  paresthesia,  or  anesthesia. 
Polyuria  may  or  may  not  be  present.  Some  patients  remain  in  compara- 
tively good  condition,  while  others  emaciate. 

The  digestive  disturbances  are  usually  independent  of  the  quantity  and 
character  of  the  food,  and  are  not  always  connected  with  the  act  of  diges- 
tion. Errors  in  diet  are  often  not  followed  by  an  exacerbation  of  the 
symptoms,  and  sometimes  they  occur  when  the  simplest  food  has  been 
taken. 

The  gastric  secretion  and  motor  functions  are  often  variable.  We 
may  find  hyperchlorhydria  at  one  time  and  normal  secretion  at  another,  or, 
conversely,  normal  conditions  may  alternate  with  hypo-acidity  or  anacid- 
ity.     At  times  the  motor  functions  may  be  normal,  at  others,  diminished. 

TJie  condition  of  the  bowels  also  varies;  there  may  be  constipation  al- 
ternating with  diarrhea;  or  the  bowels  may  be  regular  and  a  sudden  diar- 
rhea appear. 

Climate  and  surroundings  may  influence  the  condition. 

SENSORY  NEUROSES  OF  THE  STOMACH 

There  may  be  abnormal  sensations  more  or  less  general  in  character 
external  to  the  stomach,  such  as  regarding  hunger,  appetite,  or  abnormal 
sensations  within  the  stomach  itself. 

Among  the  abnormal  sensations  of  appetite  are  bulimia  (or  canine 
hunger) ;  parorexia  (perversion  of  appetite) ;  polyphagia  (excessive  eating) ; 
akoria  (absence  of  satiation);  anorexia  (loss  of  appetite). 

Bulimia 

Bulimia,  hyperorexia,  or  canine  hunger  (cynorexia)  denotes  a  marked 
increase  of  the  sensation  of  hunger  which  may  occur  in  attacks,  either  as 
an  independent  neurosis  or  as.  a  secondary  affection,  the  result  of  some 
other  disease.  The  attacks  are  paroxysmal.  The  hunger  center  is  be- 
lieved to  be  located  in  the  medulla.  This  center  is  probably  irritated 
when  a  certain  degree  of  impoverishment  of  the  blood  takes  place.  On 
the  other  hand,  if  the  latter  is  marked,  the  sensation  of  hunger  may  not 
be  produced  or  may  even  be  suppressed.  The  stomach  is  also  concerned 
in  its  production,  and  the  amount  of  food  contained  therein  has  an  influ- 
ence. For  example,  with  hyperacidity  and  increased  motor  function, 
hunger  is  present.  In  a  case  of  mine  suffering  from  stenosis  of  the  pylorus 
and  dilatation  of  the  stomach,  while  before  operation  anorexia  was  marked, 
the  patient  is  now  continuously  hungry.  Reflexly,  the  hunger  center  is 
often  disturbed;  this  loss  of  appetite  may  occvur  after  fright,  or  on  the 
appearance  of  food  that  is  greasy  and  badly  served,  whereas  with  food 
daintily  prepared  and  of  pleasant  odor,  the  appetite  is  increased.  The 
olfactories  have  also  undoubtedly  an  influence  on  the  digestion.^  For 
example,  it  requires  about  2000  cubic  feet  of  air  to  pass  daily  through  the 
lungs  to  furnish  sufficient  oxygen  to  maintain  digestion.     As  the  greater 

*  Niles,  Jour.  Amer.  Med.  Assoc,  Oct.  16,  1909,  vol.  liii,  pp.  1 274-1 278. 


NERVOUS    AFFECTIONS    OF    THE    STOMjVCH  47 1 

part  of  the  air  passes  over  the  olfactory  region,  the  contact  of  odorous 
substances  may  exert  a  marked  influence.  Moreover,  appetizing  odors 
may  stimulate  the  salivary  glands  and  the  flow  of  the  gastric  juice;  while 
repulsive  smells  may  lessen  the  appetite,  inhibit  the  secretion  of  the  gastric 
juice,  and  lessen  the  motility  of  the  stomach  and  the  salivary  gland  secre- 
tion. The  time  at  which  hunger  appears  depends  on  the  time  the  person 
is  accustomed  to  eat. 

Pathologically  the  sensation  of  hunger  may  also  be  stimulated  or 
inhibited  in  various  ways. 

Etiology. — Bulimia  may  be  a  primary  affection  or  may  be  secondary 
to  ulcer  of  the  stomach,  hyperchlorhydria,  hypersecretion,  epilepsy,  hys- 
teria, neurasthenia,  tumor  of  the  brain,  tapeworm,  intestinal  diseases, 
rarely  to  diseases  of  the  pancreas  or  to  diabetes  mellitus. 

Occurrence. — It  is  more  frequent  in  women  than  in  men,  and  most 
frequent  from  eighteen  years  of  age  to  menopause. 

Sjmiptoms. — ^The  patient  may  be  in  perfect  health,  when  suddenly  a 
feeling  of  intense  hunger  comes  on  which  is  extremely  persistent  and  calls 
for  food.  There  is  frequently  a  gnawing  in  the  stomach  and  a  feeling  of 
fear  and  anxiety.  Unless  the  hunger  is  relieved,  headache,  trembling, 
and  even  fainting  spells  may  occur.  The  attack  may  take  place  immedi- 
ately after  a  large  meal,  or  come  on  in  the  night.  In  some  cases  small 
amounts  of  food  will  relieve  the  conditions;  in  others,  enormous  quantities 
are  necessary.  One  patient  recorded  ate  23  eggs  in  forty-five  minutes 
and  drank  1}.^  quarts  of  milk  and  i  quart  of  wine. 

Character  of  Attacks. — They  may  be  severe  or  very  slight.  In  some 
cases  they  occur  every  few  hours;  in  others  they  last  a  few  days,  or  they 
may  exist  chronically  and  last  for  years.  The  periodic  form  is  generally 
more  intense.     Hypermotility  is  found  in  some  cases. 

Prognosis. — In  the  secondary  form  it  depends  on  the  primary  disease, 
though  sometimes  bulimia  persists.  The  more  frequent  and  violent  the 
attacks,  the  worse  the  prognosis.  Ordinarily  it  is  difficult  to  give  an 
absolute  prognosis.  Gastritis,  atony,  or  dilatation  of  the  stomach  may 
result  in  some  cases. 

Treatment. — If  bulimia  is  secondary,  the  primary  disease  should  be 
treated,  such  as  hyperchlorhydria,  tapeworm,  diabetes,  or  neurasthenic 
or  hysteric  symptoms.  For  the  bulimia  we  should  give  frequent  light 
meals  every  two  hours.  The  bromid  of  sodium,  potassium,  ammonium, 
or  strontium  may  be  given  in  20-grain  to  i-^-dram  (1.3-2.0)  doses  two  or 
three  times  daily;  for  example: 

I^.  Sod.  bromid 5iiss  (lo.o) ; 

Aq.  menth.  piperit , q.  s.  5iv  (125  c.c). — M. 

Sig. — Two  teaspoonfuls  in  water  t.i.d.  after  meals. 

Codein,  opium,  and  cocain  I  strongly  deprecate,  though  recommended 
by  some.     There  is  great  danger  of  acquiring  the  habit. 

Tincture  belladonna,  10  minims  (0.59  c.c.)  t.i.d.,  is  a  good  substitute. 

Arsenic  (Fowler's  solution),  5  minims  (0.296  c.c),  or  sodium  arsenate, 
Ho  to  >^5  grain  (0.0013-0.0026),  or  arsenous  acid,  Koo  grain  (0.00065) 
t.i.d.,  are  useful. 


472  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Iron  can  be  given,  also  strychnin,  }4o  grain  (0.00108),  for  the  nerves. 
Change  of  climate  is  of  value.     Food  should  be  carried  by  those  suffer- 
ing from  abnormal  hunger  for  immediate  use. 

Parorexia  (Perversion  of  Appetite) 

Sometimes  the  appetite  is  manifested  for  special,  or  peculiar  kinds  of 
food.     There  are  three  types: 

(i)  Malacia,  a  desire  for  spiced  foods,  such  as  for  mustard,  vinegar, 
green  fruits,  etc. 

(2)  Pica,  a  desire  for  substances  that  are  not  foods,  such  as  earth, 
chalk,  ashes,  sand,  insects,  etc. 

(3)  Allotriophagia,  a  craving  for  disgusting  and  harmful  substances, 
such  as  fecal  matter,  pins,  etc. 

Malacia  is  met  with  in  disturbances  of  the  stomach  and  neurasthenia, 
while  the  other  t5^es  occur  chiefly  in  idiots,  lunatics,  or  with  severe 
hysteria.  The  treatment  is  of  the  disease  which  is  the  cause  of  the 
perversion. 

Polyphagia 

Polyphagia  is  the  demand  for  large  quantities  of  food  before  satiation 
occurs.  The  cases  do  not  feel  hungry  until  the  food  is  digested.  It  may 
occar  as  a  primary  condition  in  neurotics,  or  secondary  to  diseases  of  the 
gall-bladder,  spleen,  diabetes,  or  brain  tumor.  The  attacks  may  be  of 
shoit  duration  or  as  a  chronic  trouble.  One  case  could  eat  100  pounds 
of  meat  in  twenty-four  hours. 

Disease,  if  present,  should  be  treated,  neurotic  conditions  should  be 
corrected.     The  general  treatment  is  the  same  as  of  bulimia. 

Akoria 

Akoria  is  absence  of  satiety.  Patients  with  akoria  never  feel  satiated, 
and  never  know  when  to  stop  eating.  It  is  at  tinaes  combined  with  poly- 
phagia. It  is  met  with  among  the  neurasthenic  and  hysteric.  Bromids 
are  of  service  and  the  general  treatment  of  the  nervous  condition. 

Nervous  Anorexia  (Anorexia  Nervosa) 

Anorexia  is  diminution  or  loss  of  appetite,  with  absence  of  the  hunger 
sense,  so  that  even  aversion  to  food  may  be  present. 

It  occurs  in  most  of  the  organic,  as  well  as  in  the  functional  disorders 
of  the  stomach,  but  the  nervous  type  appears  as  a  primary  affection. 

It  has  been  attributed  to  a  depressed  condition  of  the  hunger  center 
or  to  hyperesthesia  of  the  mucous  membrane  of  the  stomach. 

Etiology. — Psychic  shock,  some  mental  depression,  worry,  a  disagree- 
able odor,  or  some  nauseating  sight  may  cause  transitory  anorexia  in  a 
healthy  person. 

It  may,  however,  be  more  persistent  in  hysteria,  neurasthenia,  and  the 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  473 

psychoses;  morphin  and  excessive  smoking  may  produce  it.  It  is  more 
frequent  in  women  and  may  result  from  anemia  or  chlorosis. 

Symptoms. — There  is  at  first  loss  of  appetite,  and  the  patient  begins 
to  eat  less.  These  cases  may  first  have  an  aversion  to  meat,  and  later  to 
bread  and  butter,  vegetables  and  all  solid  food,  and  may  finally  live  only 
on  fluids,  sometimes  on  very  small  quantities.  They  often  vomit  at  the 
sight  or  smell  of  food,  and  may,  in  severe  cases,  emaciate  markedly.  They 
will  refuse  to  increase  their  nourishment  ("  siturgy  ").  The  pulse  becomes 
slow  and  the  temperature  subnormal;  they  become  pale,  cyanotic,  and 
the  eyes  sunken.  Such  cases  may  even  terminate  fatally.  This  condition 
may  be  mistaken  for  organic  disease  or  for  phthisis,  and  a  careful  physical 
examination  and  gastric  analysis  should  be  made. 

Treatment. — -The  patient  should  be  impressed  with  the  idea  that  he 
must  take  his  food  in  sufficient  quantity  and  eat  everything  put  before 
him.     He  should  not  be  questioned  as  to  his  desires. 

Frequent  small  meals  with  koumiss,  matzoon,  bacillac,  fermillac, 
lactone-butter-milk,  butter,  milk,  and  cream  should  be  given  to  improve 
nutrition.     Raw  eggs  are  of  service. 

The  sour  milk  products  are  of  value,  as  auto-intoxication  is  an  im- 
portant feature  in  these  neurasthenics. 

Stomachics,  such  as  tincture  of  nux  vomica,  10  minims  (0.59  c.c.) 
t.i.d.,  and  fluidextract  of  condurango,  20  minims  (1.184  c.c),  are  of  service. 
Fluidextract  of  Peruvian  bark,  i  dram  (4.0)  t.i.d.,  is  excellent. 

I^.  Tr.  nucis  vomicae,         \  .._-../„    x 

Acid,  hydrochlor.  dil.  / ^^  ^'^  ^"•°''' 

Comp.  tinct.  cinchona 5ss  (16.0); 

Aq.  destil q.  s.   5iv  (125.0). — M. 

Sig. —  3]  to  ij  (4.0-8.0)  t.i.d.  in  water  before  meals. 

Basic  orexin,  3^  to  >^  grain  (0.02-0.03)  t.i.d.,  may  prove  of  service. 
Morphin  and  tobacco,  if  they  are  factors,  should  be  cut  off. 

Sanatorium  treatment  and  rest  cure  are  important  in  severe  cases, 
especially  by  the  Weir-Mitchell  method.  Isolation  from  the  family, 
strict  supervision  by  the  physician,  massage,  and  electricity  are  valuable. 

Forced  feeding  (gavage)  or  nutritive  enemata  may  be  required.  After 
a  while  the  patient  will  be  convinced  she  can  digest  food.  Small  quanti- 
ties are  given  at  first,  and  then  they  are  increased.  In  milder  cases  change 
of  climate  is  useful. 

Strychnin,  >^o  to  3^0  grain  (0.001-0.002),  Blaud's  iron  pills,  or  iron 
tropon  are  of  service.  Arsenic  may  be  added,  Fowler's  solution,  5  minims 
(0.29),  sodium  arsenate,  %q  to  %q  grain  (0.001-0.002),  glycerophosphates 
of  soda,  or  Chapoteaut's  glycerophosphate  of  lime.  These  remedies 
should  be  given  t.i.d. 

Sensations  within  the  Stomach 

Under  normal  conditions  we  do  not  recognize  that  we  have  a  stomach, 
and  there  are  no  sensations  after  the  ingestion  of  food.  The  stomach  is 
not  devoid  of  sensation  even  normally,  as  excessive  quantities  of  hot  or 


474  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

cold  material  are  noted  by  internal  sensations,  such  as  after  the  ingestion 
of  a  large  quantity  of  ice-cream  on  an  empty  stomach. 

Gastric  sensation,  however,  may  be  increased  to  a  pathologic  degree 
and  be  a  source  of  great  discomfort.  We  must  remember  that  certain 
persons  are  peculiarly  constituted  and  have  idiosyncrasies  to  particular 
foods. 

Idiosyncrasies. — For  example,  shell-fish,  such  as  lobsters,  crabs,  and 
oysters,  strawberries,  bananas,  onions,  etc.,  will  produce  skin  eruptions 
such  as  urticaria  or  erythema,  and  gastric  symptoms  such  as  pain,  belch- 
ing, pressure,  and  even  nausea  or  vomiting.  Talma  and  Einhorn  have 
described  cases  having  a  peculiar  idiosyncrasy  to  hydrochloric  acid.  I 
have  seen  several  cases  where  the  patient  suffered  from  the  symptoms  of 
hyperchlorhydria,  and  yet  the  free  hydrochloric  acid  found  was  well  within 
normal  limits.  The  administration  of  alkalis  relieved  the  symptoms. 
The  gastric  nerves  were  evidently  peculiarly  sensitive  to  acid  in  these  cases. 
If  patients  have  an  idiosyncrasy  to  special  food,  it  must  be  avoided. 

Abnormal  Sensations  (Sensory  Neuroses  of  the  Stomach) 

The  nervous  and  hysteric  at  times  complain  of  sensations  of  heat, 
cold,  or  of  some  foreign  body,  such  as  the  feeling  of  worms,  etc.,  within 
the  stomach.  These  symptoms  are  not  dependent  on  the  food  or  upon  the 
gastric  secretion.  There  may  be  in  some  a  feeling  of  constriction,  cramp, 
or  "pulsation"  within  the  stomach.  The  latter  is  probably  due  in  many 
cases  to  hyperesthesia  and  the  transmission  of  the  aortic  pulsation. 

Nausea. — There  may  be  a  nervous  type  of  nausea  in  such  patients, 
either  during  the  fasting  condition  or  after  meals,  the  treatment  for  which 
should  be  directed  to  the  neurasthenia.  Nausea  may  also  be  reflex,  as 
from  an  affection  of  the  genital  organs,  or  in  organic  disease  of  the  stomach. 
Einhorn  recommends  intragastric  galvanization. 

The  indication,  however,  is  to  treat  the  hysteria  or  neurasthenia. 

Hyperesthesia  of  the  Stomach 

This  consists  in  an  increased  sensibility  of  the  nerves  of  the  stomach, 
so  that  the  mucous  membrane  is  abnormally  sensitive  even  after  ordinary 
food  is  taken.  It  differs  only  in  degree  from  gastralgia.  It  may  be  sec- 
ondary to  organic  affections,  associated  with  secretory  disturbances,  or  it 
occurs  as  a  primary  neurosis. 

Etiology. — It  is  present  especially  in  the  higher  classes.  Mental  over- 
exertion, excitement,  alcohol,  and  veneral  excesses,  which  weaken  the 
constitution,  are  factors.  It  is  associated  with  hysteric,  or  nervous  symp- 
toms. Though  anemia  is  given  as  a  cause,  hyperchlorhydria  with  hyper- 
esthesia occur  with  this  condition,  and  this  type  is,  therefore,  not  a  pure 
sensory  neurosis. 

Symptoms. — There  is  a  sensation  of  fulness,  weight,  or  pressure  after 
meals,  which  may  become  real  pain,  and,  finally,  vomiting  may  occur. 
Sometimes  considerable  emaciation  is  present,  as  the  patient  fears  to  eat 


NERVOUS   AFFECTIONS    OF    THE    STOMACH  475 

(sitophobia).  Hyperesthesia  occurs  after  excess  of  food  or,  in  some,  in 
cases  of  fasting.     Persistent  hiccough  may  occur  with  this  condition. 

Physical  Signs. — The  epigastrium  and  region  of  the  stomach  are  sensi- 
tive to  pressure  throughout,  but  there  is  no  specially  sensitive  area  as  in 
ulcer. 

Certain  articles  of  food,  such  as  sugar,  fat,  starch,  or  coffee,  may  pro- 
duce the  condition.  The  secretory  and  motor  functions  are  normal  in 
the  purely  nervous  cases. 

Diagnosis. — This  is  based  on  the  absence  of  organic  disease  of  the 
stomach,  the  absence  of  hyperchlorhydria,  or  of  other  secretory  disturb- 
ances, and  the  absence  of  motor  disturbances.  With  hyperchlorhydria 
and  gastritis  the  gastric  analysis  and  other  symptoms  will  give  us  the  requi- 
site differential  points.  With  ulcer,  hyperacidity  is  the  rule,  and  the  de- 
gree of  pain  is  dependent  considerably  on  the  character  of  the  food,  which 
is  not  generally  so  in  hyperesthesia;  the  other  symptoms  also  differ. 

With  erosions  small  bits  of  mucous  membrane  are  washed  out  and 
there  are  secretory  changes. 

Prognosis  depends  on  the  result  of  the  treatment  of  the  nervous  con- 
dition. 

Treatment. — In  many  of  these  cases,  as  when  anemia  is  present, 
secretory  disturbances  are  associated  with  the  sensory  neurosis,  as  hyper- 
chlorhydria, so  that  the  pure  sensory  condition  is  often  complicated. 
Iron  and  arsenic  are  necessary  in  such  cases  and,  in  fact,  have  an  excellent 
effect.  Iron  tropon,  or  any  good  iron  preparation  combined  with  Fowler's 
solution,  5  minims  (0.296  c.c.)  t.i.d.,  is  excellent.  The  Blaud  pill  gr.  v, 
combined  with  sod.  arsen.  gr.  J^o  and  strych.  sulp.  gr.  }io  is  good. 

The  patient  should  be  kept  in  bed  in  severe  cases  and  warmth  applied 
to  the  stomach,  dry  heat,  or  Priessnitz  compresses.  Fluid  diet  in  rather 
small  quantity  should  first  be  given.  Milk  and  lime-water,  broths, 
chicken  soup,  white  of  egg,  later  entire  raw  eggs  beaten  in  water,  calves'- 
foot  jelly,  scraped  meat,  zwieback  softened  in  milk,  butter,  and,  gradually, 
solid  food  should  be  administered. 

Tincture  of  belladonna,  5  to  10  minims  (0.296-0.592)  t.i.d,,  is  ex- 
cellent for  the  pain.  The  use  of  opium  and  its  derivatives  and  cocain  are 
to  be  deprecated.     Rarely  an  occasional  dose  of  codein  may  be  required. 

In  some  cases  silver  nitrate,  }^^  to  3^^  grain  (0.008-0.016),  in  aqueous 
solution  t.i.d.  before  meals  is  of  service. 

External  galvanization  to  the  stomach  is  of  value.  Bromids  in  some 
cases  are  serviceable. 

Baths  and  change  of  scene  may  be  enjoined.  Treatment  by  "sugges- 
tion" should  be  used  by  the  physician. 

Gastralgia 

iSynanynts. — Gastxodynia,    Spasm    of    the    Stomach    (Gastrospasmus) ;    Cardialgia, 
Neuralgia  of  the  Stomach) 

Gastralgia  may  be  defined  as  the  occurrence  of  violent  attacks  of  pain 
in  the  stomach,  paroxysmal  in  character  and  alternating  with  free  inter- 
vals. 


476  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

Etiology. — We  may  have  a  number  of  forms  of  gastralgia  originat- 
ing from  various  conditions,  and  these  must  be  referred  to  in  order  to 
differentiate  them  from  the  purely  nervous  type. 

Gastralgia  Originating  in  the  Stomach. — (a)  Connected  with  Organic 
affections,  such  as  ulcer,  cancer,  stenosis  of  the  pylorus,  or  gastritis, 
hyperacidity,  hypersecretion,  hypoacidity,  peritonitic  adhesions,  or  with 
perigastritis. 

{b)  Special  varieties  of  food,  as  rich  spices,  or  of  drink,  as  strong 
coffee,  or  ice  cream,  etc.,  may  produce  it  in  people  not  accustomed  to 
these  substances. 

Spinal  disease,  as  tabes,  may  cause  gastric  crises,  or,  more  rarely,  cere- 
bral disease  or  various  types  of  myelitis.  Absence  of  patellar  reflex, 
Argyll- Robertson  pupil,  and  Rhomberg  symptom  are  diagnostic  of  tabes. 
Wassermann  test  should  also  be  made. 

Gastralgia  as  a  Neurosis. — This  occurs  with  neurasthenia  or  hysteria. 
It  may  appear  before  the  nervous  symptoms  are  in  evidence. 

Reflex  Causes. — Gastralgia  of  this  type  occurs  most  frequently  in 
women.  It  takes  place  reflexly  from  disturbances  in  the  female  or  in 
the  male  genital  organs.  Gastralgia  may  occur  at  the  time  of  menstrua- 
tion or  in  place  of  it. 

Disease  of  the  liver,  spleen,  bladder,  pancreas,  and  ptosis  of  abdominal 
organs  may  be  reflex  causes. 

Other  Causes. — Malarial  infection  may  be  a  cause  of  gastralgia.  The 
latter  may  be  associated  with  the  usual  symptoms  of  malaria  or  it  may 
be  substituted  for  the  malarial  cycle,  appearing  every  day,  alternate  day, 
or  third  day  at  the  same  hour,  as  do  other  neuralgias. 

Gouty  infection,  mercurial  or  lead-poisoning,  or  excessive  smok- 
ing may  produce  it.  Exophthalmic  goiter,  anemia,  or  chlorosis  with 
malnutrition  may  be  a  cause,  although  the  attacks  in  many  of  these 
cases  are  the  result  of  the  associated  hyperchlorhydria. 

Sex. — It  occurs  most  frequently  in  women  and  girls  from  fifteen  to 
forty,  and  decreases  in  frequency  with  age. 

Symptoms. — The  attacks  usually  appear  suddenly  and  occur  in 
paroxysms,  though  they  may  be  preceded  by  nausea,  with  belching 
and  distention,  headache,  or  dizziness.  There  is  a  sudden  extreme 
pain  in  the  epigastric  region  of  a  boring,  tearing,  burning,  and  constricting 
character.  It  may  radiate  over  the  abdomen  or  to  the  back  and  shoulders. 
The  attacks  may  occur  independently  of  eating  and  whether  the  stomach 
is  empty  or  full,  or  at  any  hour  {in  the  nervous  cases). 

The  face  is  pale  and  distorted  with  the  pain,  by  which  the  patient 
is  frequently  doubled  up,  as  with  colic,  and  there  is  inability  to  lie  straight, 
and  often  clammy  sweating.  Strong  pressure  on  the  abdomen  frequently 
relieves  the  pain,  though  it  may  be  sensitive  to  lighter  pressure.  The 
gastric  region  is  usually  sunken. 

There  are  often  hiccough  and  belching,  with  nausea  and  collapse. 
The  pulse  is  generally  rapid  and  feeble,  though  in  some  cases  slow. 

Duration. — Gastralgic  attacks  may  last  from  a  few  minutes  to  an 
hour  or  longer.  There  may  be  several  attacks  in  a  day,  every  few  days, 
or  at  intervals  of  weeks  or  months. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  477 

The  pain  disappears  suddenly  and  may  be  followed  by  hunger  or 
even  bulimia.  In  mild  cases  the  patient  may  not  be  greatly  affected 
and  may  be  able  to  work  immediately,  while  in  the  severe  cases  there  is 
often  prostration  for  several  days. 

Prognosis  is  favorable  as  far  as  life,  and  depends  on  the  removal 
of  the  primary  cause. 

Differential  Diagnosis. — The  sudden  onset,  violent  spasmodic  pain 
in  the  stomach,  general  in  character  and  lessened  by  pressure,  nausea, 
vomiting,  and  headache — that  these  symptoms  are  independent  of  eating 
and  freqiiently  occur  after  mental  overexertion  or  emotional  shock  and  are 
associated  with  nervous  hysteric  symptoms — all  point  to  the  nervous 
type. 

We  must  exclude  the  secondary  form  by  gastric  analysis,  and  by 
the  determination  that  no  organic  disease  exists.  A  careful  physical 
examination  is  necessary,  thereby  eliminating  other  conditions  that 
may  cause  pain  in  the  gastric  region. 

Ulcer  of  the  Stomach. — The  pain  at  the  height  of  digestion  depends 
on  the  quantity  and  quality  of  food;  disappears  when  the  stomach  is 
empty;  intervals  free  from  pain;  h)^erchlorhydria  often  present;  cir- 
cumscribed spot  in  the  epigastrium  painful  on  pressure  and  increased 
•by  it;  left  dorsal  pain  present,  hematemesis  present  in  some  cases,  or 
occult  blood  and  pus  in  gastric  contents  or  stool.  If  these  characteristic 
symptoms  are  absent  it  may  be  necessary  to  try  one  of  the  ulcer  cures; 
which,  if  it  fails,  would  rather  point  toward  nervous  gastralgia.  The 
:c-rays  would  determine  the  presence  of  ulcer  in  doubtful  cases. 

Cancer  of  the  Stomach. — Pains  not  as  severe,  but  more  continuous, 
never  free  from  pain;  absence  of  hydrochloric  acid  most  frequent;  lactic 
acid  and  Boas-Oppler  bacilli  present;  cachexia;  loss  of  weight;  age  of 
patient  usually  forty  to  sixty  years;  tumor  often  present. 

Chronic  Gastritis. — -Intense  pains  are  absent;  are  continuous  and 
more  a  sense  of  discomfort  after  the  ingestion  of  food;  no  paroxysms; 
mucus  in  gastric  contents;  hypochlorhydria. 

Stenosis  of  the  Pylorus. — Attacks  of  pain  (gastralgia),  associated 
with  peristaltic  unrest  and  vomiting.  Dilatation  of  the  stomach  is 
present;  usually  hyperacid  contents  if  benign  stenosis;  and  lactic  acid 
present  with  absence  of  free  HCl  and  Boas-Oppler  bacilli  if  malignant. 

Functional  Disorders. — Hyperchlorhydria  and  hypersecretion;  pains 
disappear  after  albuminous  food  or  alkaUs.  Gastric  analysis,  hyper- 
acidity, and  if  hypersecretion,  excessive  quantity  of  secretion  in  the 
empty  stomach,  of  high  acidity,  afford  information. 

Achylia  Ga^trica. — Pains  disappear  when  stomach  is  empty.  Gastric 
analysis  shows  low  acidity,  2-}-  or  4 4-;  free  HCl  absent;  rennet  =  o; 
pepsin  =  o. 

Tabes. — Gastralgic  attacks  may  be  very  severe.  Absence  of  patellar 
reflexes,  the  Argyll-Robertson  pupil  and  the  Rhomberg  symptom  are  diag- 
nostic. Wassermann  reaction  should  be  tested  for  and  is  diagnostic  in 
doubtful  cases. 

Rheumatism  and  Myalgia. — Myalgia  is  muscular  pain  which  may 
be  due  to  exertion.     In  both  conditions  when  occurring  in  the  abdominal 


478  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

muscles  the  pain  is  not  paroxysmal;  corresponds  to  the  course  of  the 
muscles,  and  is  relieved  by  abdominal  relaxation;  we  have  a  rheumatic 
history  or  that  of  overexertion. 

Intercostal  Neuralgia. — Pain  is  superficial  and  can  be  traced  along 
the  intercostal  nerves,  which  are  sensitive  at  numerous  points  on  pressure. 

Renal  Calculi. — Pain  in  the  kidney  (dorsal  region)  radiates  to  the 
ureter  and  bladder;  testicle  drawn  up  in  the  male;  urine  is  acid  and 
shows  albumin,  casts,  and  blood.  Sand  often  present.  Kidney  is  fre- 
quently tender  on  pressure. 

Gall-stones. — Pain  over  liver  and  gall-bladder;  deep  pressure  increases 
the  pain;  rise  of  temperature;  pain  passes  to  right  and  often  up  into  the 
right  shoulder.  Head's  gall-bladder  zone  often  present.  Leukocytosis 
frequently  present.     Right  dorsal  tenderness  at  Boas  point  at  times. 

Jaundice  occurs  at  times  and  gall-stones  in  the  stool  are  conclusive 
though  often  not  found. 

If  the  motor  or  secretory  Junctions  of  the  stomach  are  normal,  the  attack 
of  pain — especially  if  it  is  in  the  right  hypochondrium  and  the  patient  has 
no  nervous  symptoms— is  probably  due  to  gall-stones. 

With  gastralgia  there  are  no  pain  and  no  fever.  It  is  sometimes 
difficult  to  differentiate  between  the  other  conditions. 

Perigastritis. — A  high  position  of  the  stomach,  with  the  left  lobe 
of  the  liver  drawn  down  and  covering  that  organ,  is  suggestive  of  peri- 
gastritis when  pains  come  on  regularly  several  hours  after  meals  (Kauf- 
mann).^  The  :r-rays  are  of  great  value  in  determining  abnormal  positions 
or  shape  of  the  stomach  resulting  from  adhesions. 

Intestinal  Colic  {Enter algia). — Pain  changes  its  position  in  the  ab- 
dominal cavity.     Passage  of  flatus  relieves  pain.     Bowels  are  irregular. 

Treatment. — In  secondary  gastralgia  it  is  necessary  to  treat  the  pri- 
mary cause. 

If  it  is  due  to  tobacco,  it  should  be  cut  off.  Malaria  should  be  treated 
with  quinin  or  Warburg;  and  anemia,  with  iron  and  arsenic  and  the  rest 
cure.  Correct  a  gouty  tendency,  if  present;  or  treat  tabes,  if  this  be 
found. 

Sexual  disorders,  ulcer,  gall-bladder  disease,  or  cancer  should  receive 
appropriate  treatment. 

If  hysteria  or  neurasthenia  are  present,  tonics,  isolation,  the  rest 
cure,  massage,  and  hydrotherapy  are  of  value. 

The  galvanic  current,  the  anode  over  the  stomach,  or  intraventricular 
galvanization,  with  the  cathode  over  the  spinal  column,  is  of  service 
when  repeated  attacks  of  primary  gastralgia  occur. 

For  the  active  condition,  if  moderately  severe,  hot  applications  (dry  or 
moist  heat)  and  hot  drinks  are  useful. 

Tincture  of  belladonna,  10  to  15  minims  (0^592-0.088),  to  relieve 
the  spasm.  Tincture  of  valerian,  20  minims  to  "^i  dram  (i.  184- 2.0), 
in  comp.  tinct.  of  lavender  and  water,  or  Hoffmann's  anodyne,  yi  dram 
(2.0),  may  be  given  in  water  with  sugar.  Chloroform  spirits,  2  to  3 
drops  in  water  at  a  dose,  can  be  administered.  The  bromids  are  also 
valuable. 

'  Amer.  Med.,  vol.  vi,  No.  20,  pp.  792,  794,  Nov.  14,  1903. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH 


479 


If  there  is  retention  of  food  during  the  attack,  then  lavage  with 
warm  water  or  saline  solution  will  relieve  some  cases. 

If  the  pain  is  unbearable,  codein,  >^  grain  (0.032),  by  hypodermic, 
or  morphin,  ]4  grain  (0.016),  with  atropin,  Hoo  grain  (0.00065),  can  be 
administered. 

Suppositories  of  morphin,  K  grain  (0.016),  and  extract  of  bella- 
donna, 3^  grain  (0.016),  or  opium,  i  grain  (0.065),  and  extract  of  bella- 
donna, K  grain  (0.016),  every  two  to  three  hours  for  several  doses, 
are  useful.  Opiates  should  be  used  with  caution  even  by  the  physician 
lest  habit  result. 

Gastralgokenosis  (Boas^) 

This  is  characterized  by  pain  in  the  stomach  when  it  becomes  empty, 
and  is  relieved  by  food.  It  may  be  periodic  or  permanent.  Frequent 
meals  and  nerve  sedatives  are  required. 

MOTOR  NEUROSES  OF  THE  STOMACH 

Under  normal  conditions,  the  cardia  remains  closed  after  the  process 
of  digestion  has  begun,  while  the  pylorus  opens  at  intervals  to  allow  a 
certain  amount  of  escape  of  chyme.  The  muscular  movements  of  the 
stomach  mix  the  ingesta  with  the  gastric  juice  and  aid  in  its  disintegration 
by  churning  movements.  Later  they  propel  it  into  the  intestine.  These 
motor  functions  may  be  irritated  (exaggerated)  or  depressed  (diminished). 

Hypermotility  of  the  Stomach 
(5y»o»yw5.— Supermotility;  Hyperkinesis;  Hyperanakinesis  Ventriculi — Einhorn) 

In  this  condition  the  stomach  propels  the  ingesta  into  the  intes- 
tines more  rapidly  than  normally. 

Etiology. — -Hypermotility  may  be  secondary  to  achylia  gastrica  or 
hyperchlorhydria  or  diseases  complicated  thereby,  or  the  condition  may 
exist  as  a  primary  neurosis.  It  may  occur  as  a  radiological  sign  of  duo- 
denal ulcer  and  at  times  with  gastric  ulcer  or  early  gastric  cancer  near  the 
pylorus,  but  not  producing  stenosis. 

In  some  cases  achylia  and  hyperchlorhydria  exist  as  a  secretory 
neurosis,  and  with  this  there  is  the  motor  neurosis,  hypermotility. 

Supermotility  may  exist  as  a  motor  neurosis  alone  (primary  neurosis) 
or  be  due  to  some  nervous  influence  or  associated  with  nervous  con- 
ditions, and  is  analogous  to  increased  intestinal  peristalsis  from  nervous 
influence.  It  occurs  with  vagotonia.  In  pyloric  obstruction  there  is 
often  actual  increased  motor  power  in  the  early  stages,  but  the  resistance 
to  the  exit  is  so  increased  that  the  final  result  is  relative  motor  insufficiency. 

Diagnosis. — Aspiration  of  the  stomach  contents  will  demonstrate 
the  condition.  For  example,  one  may  find  the  stomach,  empty  thirty- 
five  to  forty-five  minutes  after  the  test-breakfast,  or  only  a  minute  quan- 
tity can  be  removed.  Radiography  should  then  be  done  so  as  to  determine 
if  there  rs  any  organic  cause  for  the  condition. 

*  Krank.  des  Magen,  II,  Feb.  418,  Auflage,  S.  260,  Leipzig,  1901. 


480  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

Einhorn  suggests  the  employment  of  the  gastrograph,  noting  an 
increase  of  the  "makes"  and  "breaks,"  but  this  method  is  compHcated. 

Careful  analysis  of  the  gastric  contents  should  be  made  to  test  the 
secretory  functions,  and  an  early  aspiration  would  be  necessary. 

Hypermotility  in  itself  does  not  produce  any  special  gastric  symptoms. 

Treatment. — In  the  secondary  cases  hypermotility  will  be  relieved  by 
treating  the  cause. 

Peristaltic  Restlessness  of  the  Stomach  (Kussmaul) 

{Synonyms. — Peristaltic  Unrest;  Tormina  Ventriculi  Nervosa) 

This  is  really  an  exaggerated  hypermotility  in  which  the  peristaltic 
action  is  unusually  great,  and  is  appreciated  by  the  patient  as  a  dis- 
agreeable sensation.  It  may  become  visible  through  the  walls  of  the 
abdomen,  and  waves  of  contraction  can  be  seen  running  from  left  to  right 
along  the  stomach.  This  condition  usually  occurs  when  there  is  ob- 
struction at  the  pylorus  or  duodenum,  with  dilatation  of  the  stomach, 
and  is  produced  by  the  effort  of  the  organ  to  overcome  the  obstruction. 

Kussmaul  first  described  two  cases  of  peristaltic  unrest  which  were 
pure  neuroses  of  motility.  The  movements  began  early  in  the  empty 
stomach  and  became  more  violent  after  eating.     Gastroptosis  was  present. 

Emotional  shock  and  abuse  from  sexual  excesses  were  the  causes. 

Mechanical  forms  must  be  excluded.  In  these,  it  occurs  only  when 
the  stomach  is  full.  In  the  nervous  cases  movements  take  place  both 
when  the  stomach  is  full  and  empty.  If  the  patient  is  well  nourished 
and  the  stomach  is  in  normal  position,  it  may  be  difficult  or  impossible  to 
see  the  movements,  but  the  patient  will  complain  of  the  contractions  and 
wave-like  movements,  and  borborygmi  and  gurgling  may  be  heard. 
Nausea,  vomiting,  and  cramp-like  pains  may  occur,  especially  in  the 
obstructive  type. 

Physical  examination  and  gastric  analysis  will  determine  whether 
the  peristaltic  restlessness  is  primary  (a  neurosis)  or  secondary,  and  the 
ic-rays  whether  there  is  organic  obstruction. 

Course  and  prognosis  depend  upon  the  cause  and  the  nervous  condition 
in  primary  cases. 

Cases  may  be  continuous,  when  they  may  cause  loss  of  sleep,  or  may 
be  intermittent. 

Treatment. — This  must  be  directed  against  the  primary  cause, 
such  as  stenosis  of  the  pylorus,  etc. 

If  it  is  a  pure  gastric  neurosis,  resulting  from  mental  overexertion, 
grief,  sexual  excess,  or  nervous  or  hysteric  conditions,  we  must  remove 
these  factors.  Iron,  arsenic,  and  the  glycerophosphates  are  indicated. 
Treat  vagotonia  if  present. 

Hydrotherapy,  diet,  and  "change  of  scene  are  valuable.  The  diet 
should  be  regulated,  all  irritants  to  the  stomach  should  be  avoided. 
The  food  should  be  digestible,  non-irritating,  and  in  moderate  quantities 
at  a  time,  especially  at  night. 

Locally,  heat  or  cold  to  the  stomach;  galvanic  electricity,  percutaneous 
or  intragastric.     This  last  is  of  no  value  in  stenotic  cases,  but  does  harm. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  481 

Lavage  is  indicated  if  there  are  stenosis  and  dilatation  as  a  tem- 
porary measure  with  operation  for  permanent  cure. 

Antiperistaltic  Restlessness  of  the  Stomach 

In  rare  cases  the  peristaltic  action  is  reversed,  the  waves  running 
from  right  to  left.     These  cases  are  generally  of  neurotic  origin. 

Intestinal  waves  are  of  small  caliber  and  move  in  different  direc- 
tions in  various  regions,  while  gastric  waves  are  of  large  size  and  move 
in  the  gastric  region.  These  waves  may  extend  to  the  intestines  and 
colored  enemata  have  been  voided  from  the  mouth  (Osier). 

Treatment  should  be  directed  to  the  neurosis. 

Incontinence  of  the  Pylorus 
{Synonym. — InsuflSciency  of  the   Pylorus) 

This  condition  was  first  described  by  de  Sere  and  Ebstein. 

It  may  be  caused  by  some  growth  in  the  pylorus,  keeping  the  opening 
patent,  or  by  stenosis  or  other  organic  changes,  or  when  the  pylorus 
is  relaxed  (atonic),  due  to  some  nervous  derangement,  hysteria,  or  myelitis. 

Relaxed  pylorus,  I  believe,  to  be  frequently  associated  with  atonic 
ectasy,  and  that  this  feature  accounts  for  the  absence  of  pain  and  vomiting. 
It  is  also  present  in  some  cases  of  gastroptosis.  The  relaxation  in  these 
cases  is  probably  compensatory.  /  do  not  believe  it  to  he  a  true  incontinence, 
but  merely  atony  with  weakening  of  the  pyloric  musculature,  with  no 
regurgitation. 

Ebstein  has  shown  that  if  we  attempt  to  inflate  the  stomach  with 
air.  or  CO2,  it  will  rapidly  pass  into  the  intestine  and  distend  it,  and 
gastric  tympany  is  absent.  A  diagnostic  feature  of  true  incontinence  is 
the  regurgitation  of  the  intestinal  contents  into  the  stomach.  On  aspiration  or 
lavage  in  the  fasting  condition,  intestinal  juice  and  often  a  considerable 
quantity  of  bile  will  be  found.  It  is  sometimes  present  on  aspiration  of 
the  test-breakfast  or  test-meal.  Very  little  chyme  is  present  in  these  cases, 
but  regurgitation  is  in  evidence. 

There  are  no  distinctive  clinical  symptoms  in  most  cases;  though 
Knapp^  reports  diarrhea  alone  or  alternating  with  constipation,  as  some- 
times associated,  and  also  toxemic  symptoms,  as  does  Ebstein;  and  Einhorn 
refers  to  two  cases  in  which  there  was  associated  cardiac  relaxation,  with 
belching  as  the  chief  symptom.  My  prolonged  investigations  among 
the  nervous  and  insane  lead  me  to  absolutely  disagree  with  Knapp  that 
achylia  (functional  or  organic)  and  insufficiency  of  the  pylorus  are  com- 
pounded. That  author  believes  there  is  no  functional  achylia,  and  with 
this  /  .entirely  disagree. 

Treatment. — Occasional  lavage;  strychnin,  yio  grain  (0.00146),  and 
belladonna  extract,  }i  grain  (o.oii)  t.i.d,,  with  intragastric  faradization 
(every  other  day). 

Massage  and  douches  are  serviceable. 

'  Phila.  Med.  Jour.,  May  24,  1902. 
31 


482  DISEASES   OF  THE   STOMACH   AND   INTESTINES 

Duodenal  Regurgitation  Due  to  Fatty  Foods 

Bassler^  has  drawn  attention  to  regurgitation  of  the  duodenal  contents 
into  the  stomach  in  some  cases  as  a  result  of  the  ingestion  of  fatty  foods 
and  oils  with  the  consequent  production  of  gastric  symptoms.  Fat  foods, 
such  as  milk,  fresh  cream,  butter,  eggs  and  the  native  oils  were  responsi- 
ble for  this  condition.  The  middle  aged  were  chiefly  affected  and  the 
physical  examination  of  the  stomach  and  abdomen  was  apparently  nega- 
tive in  these  patients. 

Symptoms. — Acute  gastric  pain  radiating  to  the  back,  occurring  in 
paroxysms  persisting  from  several  minutes  to  several  hours  and  sometimes 
for  several  days,  were  present.  Incapacity  from  the  pain  sometimes 
resulted,  and  when  it  suddenly  disappeared,  the  patient  was  apparently 
as  well  as  ever.  Occasionally  nausea  was  present,  but  no  vomiting. 
Considerable  anxiety  and  distress  are  produced  during  the  period  of  pain. 

Gastric  Analysis. — There  is  a  large  residuum  after  the  Ewald  meal. 
Part  of  this  consists  of  duodenal  contents,  the  aspirated  material  being 
deeply  bile-stained  and  containing  considerable  floating  fat,  fatty  acids, 
pancreatic  juice,  hydrochloric  acid  in  large  amount  and  mucus,  the  latter 
perhaps  explained  by  stomach  irritation.  The  empty  stomach,  aspirated 
in  the  morning  shows  an  accumulation  of  the  duodenal  contents  fat  and 
fatty  acids  and  small  amounts  of  hydrochloric  acid,  as  much  as  73  c.c. 
being  aspirated  in  one  patient. 

During  the  paroxysm  the  stomach  invariably  contains  these  constit- 
uents and  even  so  to  a  less  degree  when  the  pain  has  disappeared  or  when 
the  patient  has  been  on  a  fat  free  diet  for  several  days. 

It  is  known  that  the  administration  of  a  considerable  quantity  of  olive 
oil  will  produce  duodenal  regurgitation  in  many  cases  and  thus  enable  one 
to  secure  the  pancreatic  juice  for  analysis.  This  is  the  probable  explana- 
tion of  the  effect  of  the  fats  on  these  patients.  Bassler  explains  the  pain 
as  due  to  the  collection  of  the  regurgitated  material  in  the  stomach  causing 
formation  of  the  fatty  acids  from  the  oils  and  fats  and  these  together  with 
the  bile  producing  irritation  of  the  stomach. 

Treatment. — These  cases  rapidly  recover  when  a  fat-free  diet,  white 
of  eggs,  skimmed  milk  carbohydrates,  green  vegetables,  salads,  boiled 
meats,  etc.,  are  administered.  The  author  has  had  no-experience  with  this 
condition. 

Spasm  of  the  Pylorus  (Pylorospasmus) 

Spasm  of  the  pylorus  means  a  spasmodic  contraction  of  the  pyloric 
ring,  the  pyloric  canal  or  of  both.  It  is  usually  a  secondary  occurrence, 
associated  with  hyperchlorhydria,  hypersecretion,  ulcer  of  the  pylorus  or 
of  the  duodenum,  or  in  its  immediate  neighborhood;  and  in  the  latter  case 
must  be  considered  a  reflex.  It  may  result  from  irritation  of  the  stomach 
by  indigestible  diet,  by  food  that  is  too  hot  or  cold,  or  by  strong  spices, 
etc.     It  is  rare  with  carcinoma  with  abundant  lactic  acid. 

Bentijac^  described  a  case  who  drank  a  glass  of  kerosene  by  mistake, 

'  Bassler:  Diseases  of  the  Stomach  and  Upper  Alimentary  Tract. 
=  These  de  Paris,  1888. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  483 

and  who  later  developed  all  the  symptoms  of  stenosis  of  the  pylorus  and 
dilatation. 

Operation  showed  the  pylorus  normal,  but  spasmodically  contracted. 
Vomiting  ceased  after  operation. 

Pylorospasm  may  be  secondary  to  gall-stones,  gall-bladder  disease, 
to  chronic  or  protective  appendicitis,  to  kinks  according  to  Lane,  or  to 
chronic  pancreatitis  or  cancer  of  the  pancreas,  in  which  events  a  careful 
investigation  of  the  history  of  the  patient  and  the  physical  examination 
will  prove  of  service.  As  a  pure  neurosis,  spasm  of  the  pylorus  is  a  rare 
afifection,  and  is  much  rarer  than  cardiospasm.  All  possible  causes  of 
spasm  of  the  pylorus  must  first  be  excluded.  Numerous  other  factors 
are  given  as  producing  reflex  spasm  of  the  pylorus,  such  as  non-bacterial 
toxic  disturbances^  resulting  from  gout,  diabetes  and  nephritis;  bacterial 
infections,  infectious  fevers  such  as  tuberculosis  and  acute  endocarditis; 
tumors,  abscesses,  hemorrhages,  embohsm  and  emotional  states  of  the 
brain;  ocular  disturbances,  conditions  in  the  pharynx,  larynx  and  also 
in  the  lungs,  such  as  whooping  cough  and  tuberculosis;  aneurysm,  goiter, 
hepatitis,  hepatic  colic,  nephritis,  pyelitis,  renal  colic,  floating  kidney; 
pregnancy,  uterine  displacement  or  inflammation,  stenosis  of  the  cervix; 
intestinal  parasites,  hernia,  chronic  intestinal  obstruction  from  adhesions, 
bands,  etc.,  inflammation  of  the  bladder  or  prostate,  acute  infections  of 
the  peritoneum,  etc.  Though  all  these  factors  must  be  considered,  the 
author  finds  that  organic  lesions  of  the  stomach  or  duodenum  are  fre- 
quently responsible;  while  on  the  other  hand  many  cases  of  pyloric 
spasm  are  reflex  from  disease  of  the  gall-bladder  or  appendix.  Hyper- 
chlorhydria  of  marked  degree  is  also  the  cause  in  a  certain  number  of 
cases.  There  are  no  specific  symptoms  of  pure  pyloric  spasm  without 
organic  lesion  at  the  pylorus,  though  some  claim  to  have  discovered  such. 
Secretory  and  motor  disturbances  of  the  stomach  are  associated  even 
with  the  pure  spasmodic  cases.  The  history,  careful  physical  examina- 
tion, study  of  the  gastro-intestinal  functions,  and  radiographs  are  the 
requisites  for  a  successful  diagnosis. 

Repeated  spasm  of  the  pylorus,  in  conjunction  with  hyperacidity  or 
hypersecretion,  is  undoubtedly  at  times  the  cause  of  gastric  dilatation; 
and  in  some  cases  benign  stenosis  may  result  from  hypertrophy  at  the  pylorus 
caused  by  the  repeated  spasm.  Pylorospasm  with  gastric  tetany  has  been 
reported  by  Pitfield.^     Pyloric  spasm  may  occur  in  vagotonia. 

S3miptoms. — Pain,  increased  peristalsis  of  the  stomach,  and  often 
vomiting  are  present.  It  may  be  induced  by  the  patient.  The  pain  may 
radiate  from  the  middle  of  the  epigastrium.  There  may  be  local  tender- 
ness, and  at  times  the  pylorus  may  be  felt  to  contract  under  the  examining 
fingers.  There  are  discomfort  and  eructation  of  gas  or  sour  and  acrid 
fluid.  Retention  and  stagnation  of  food  may  occur  and  ultimately  dilata- 
tion of  the  stomach. 

Pure  nervous  spasm  of  the  pylorus  is  difiicult  to  diagnose.  All 
perversions  of  secretion  and  all  mechanical  obstacles  must  be  excluded 

'Haynes:  Pyloric  Spasm,  Amer.  Jour.  Surgery,  Dec,  1915. 
2  N.  Y.  Med.  Jour.,  May  31,  1913. 


484  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

as  noted.     Nervous  spasm  (pyloric)  is  most  likely  to  be  associated  with 
the  hysteric  or  neurasthenic  condition,  or  vagotonia. 

The  writer  has  seen  a  number  of  cases  of  pyloric  spasm  in  which  hyper- 
chlorhydria  was  unquestionably  the  chief  factor.  This  has  been  present 
in  a  number  of  nervous  patients,  especially  in  anemic  women,  and  the 
possibility  of  ulcer  has  been  suggested.  Cure  followed  the  treatment  of 
the  hyperchlorhydria.  In  the  pure  neurosis  cases  the  gastric  analysis 
may  vary  on  different  occasions. 

X-Rays. — Fluoroscopy,  and  more  particularly  radiography,  are  impor- 
tant for  the  purpose  of  diagnosis  and  differentiation  between  pyloric  spasm 
from  a  local  organic  cause,  or  as  a  reflex  from  some  distant  organ.  De- 
formity of  the  stomach  from  ulcer,  or  of  the  duodenum  from  ulcer  or 
adhesions,  gall-stones,  or  gall-bladder  adhesions  (from  stones  or  cholecys- 
titis), intestinal  adhesions,  or  angulations,  chronic  appendicitis  (if  appendix 
is  patent)  can  all  be  recognized  or  excluded.  A  reflex  spasm  is  usually 
unstable  and  may  not  appear  on  second  examination.  To  exclude  spasm 
tinct.  belladona  10  to  even  20  drops,  up  to  physiological  effects,  or  large 
doses  of  atropia  are  usually  given  t.i.d.  before  the  second  examination. 
Personally  I  arrive  at  my  conclusion  by  one  examination,  eliminating 
spasm  by  the  previous  use  of  belladonna  and  examine  for  various  organic 
conditions  plus  pyloric  deformity  (contraction.) 

Treatment. — Belladonna  is  of  value  to  relax  spasm  and  lessen  secretion; 
the  tincture,  10  minims  (0.592)  t.i.d.,  or  extract,  3^  grain  (0.016)  three  or 
four  times  a  day,  or  atropin,  gr.  Hoo~Mo  t.i.d.  Olive  oil  (i  to  2  ounces) 
before  meals  lessens  spasm. 

The  nervous  system  must  be  toned  up  and  bromids  may  be  of  service. 
Vagotonia  or  sympatheticotonia  must  receive  treatment.  In  the  secondary 
cases,  secretory  perversions  and  other  causes  of  the  condition  must  receive 
appropriate  treatment.     Lavage  is  necessary  if  there  is  dilatation. 

Einhorn^  has  described  and  recommended  for  treatment  of  pyloric 
spasm  a  dilating  inflatable  catheter,  and  recently  a  small  gauze  balloon 
(pyloric  dilator),  to  which  is  attached  a  long  thin  soft-rubber  tube  with- 
a  stop-cock  and  syringe  at  its  distal  end.^  A  diaphane^  is  attached  to 
the  latest  instrument,  the  light  demonstrating  when  it  has  passed  the 
pylorus.  More  recently  he  has  devised  a  double-balloon  dilator.'*  This 
method  the  writer  has  determined  to  be  unreliable,  in  fact,  no  cure  can  be 
effected  thereby  in  his  belief,  and  suggestion  that  benign  stenosis  of  the 
pylorus  can  be  cured  by  this  treatment  is  a  serious  menace  to  the  safety 
of  the  patient  by  reason  of  the  delay.  Organic  stenosis  of  the  pylorus  is 
always  a  surgical  condition.  So-called  medical  cures  of  ectasy  due  to 
stenosis  of  the  pylorus  invariably  relapse  until  surgical  measures  are 
undertaken. 

Surgery. — Appendectomy  is  indicated  if  appendicitis  is  the  cause, 
or  operation  on  the  stomach,  duodenum  or  gall-bladder  if  such  is  at  fault. 
Exploratory  laparotomy  may  be  necessary  to  determine  the  cause  of  the 

^  Med.  Rec,  Oct.  9,  1909;  III.  Med.  Jour.,  June,  1910;  Med.  Rec,  June  10,  191 1; 
Ibid,  June  10,  191 1. 

2  Med.  Rec,  Jan.  21,  191 1. 
'  Med.  Rec,  June  10,  1911. 
*  N.  Y.  Med.  Jour.,  May  11,  191 2. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  485 

pylorospasm,  and  one  may  find  that  pyloroplasty,  pylorectomy,  or  gastro- 
enterostomy, with  closure  of  the  pylorus  may  be  indicated.  Other  sur- 
gical causes  should  be  treated. 

Atony  of  the  Stomach 

This  is  a  condition  in  which  the  muscular  action  of  the  stomach  is 
retarded  and  weakened,  and  moderate  motor  insufficiency  results.  It 
may  be  acute  or  chronic  and  secondary  to  other  conditions,  or  as  a  primary 
neurosis.     It  has  been  already  fully  described. 

Hypanakinesis  Ventriculi  (Einhorn) 

This  is  defined  as  a  condition  in  which  the  mechanical  function  of  the 
stomach  is  greatly  reduced.  There  are  no  breaks,  or  few,  in  the  gastro- 
graph,an  instrument  to  determine  the  churning  movements  of  the  stomach. 
It  seems  a  minor  degree  of  atony,  and  is  of  no  special  clinical  significance. 

Hyperanakinesis  Ventriculi  (Einhorn) 

This  is  an  excessive  mechanical  action  of  the  stomach.  It  seems  to 
correspond  to  hypermotility.  Excessively  active  churning  movements 
occur  in  this  condition  (Einhorn).  It  seems  difficult  to  separate  it  from 
hypermotility. 

Spasm  of  the  Cardia  (Cardiospasmus) 

Spasm  of  the  cardia  consists  in  a  spasmodic  contraction  of  the  muscles 
of  the  cardia,  with  the  production  of  pain  and  difficulty  in  swallowing 
(dysphagia). 

Etiology. — It  may  be  produced  by  the  passage  of  the  stomach-tube 
or  after  rapid  eating,  by  very  hot  or  cold  drinks,  and  by  coarse  or  hard 
food. 

It  may  be  secondary  to  other  diseases  (organic  disease),  reflex  from 
local  irritation,  or  as  a  primary  neurosis,  associated  with  nervous  condi- 
tions or  result  from  vagotonia. 

.  Among  other  causes  are  ulcer  or  carcinoma  of  the  cardia.  H)^eracidity 
may  occasionally  cause  it,  though  pyloric  spasm  is  more  frequent  with 
this  affection.  Diverticula,  or  inflammation  of  the  esophagus,  are  causes. 
It  may  occur  in  tetanus.  It  is  quite  frequent  in  hysteric  or  neuras- 
thenic individuals,  especially  in  air  swallowers  (aerophagia),  in  whom 
spasm  of  the  pylorus  may  also  occur  with  resulting  distention  of  the 
stomach  ("pneumatosis").  Violent  psychic  shocks  may  also  produce 
it,  so  the  condition  may  be  a  primary  neurosis.  Fermentative  processes  in 
the  stomach,  with  the  production  of  gas,  may  be  a  cause;  but  organic 
disease  is  usually  associated.  Primary  spasm  of  the  cardia  cannot  produce 
gastric  distention  unless  spasm  of  the  pylorus  is  also  present. 

Sjonptoms. — As  a  pure  neurosis  the  attack  usually  begins  suddenly. 
The  patient  may  be  in  perfect  health,  when  an  acute  pain  begins  in  the 
region  of  the  cardia  radiating  toward  the  chest  or  back.     It  occurs  gener- 


486  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

ally  during  the  ingestion  of  food,  and  there  is  a  feeling  as  if  some  of  it 
were  arrested.  There  is  at  times  some  interference  with  breathing.  Slight 
dyspnea  is  present  and  the  respiratory  movements  are  more  forcible. 
There  may  be  regurgitation  and  the  patient  feels  better  thereafter. 
There  are  gagging  and  often  vomiting. 

The  attack  can  be  acute  and  last  only  a  short  time,  or  the  condition 
may  become  chronic.  The  dysphagia  in  these  cases,  as  a  rule,  increases; 
and  though  for  a  time  the  patient,  by  taking  a  deep  inspiration  and  com- 
pressing the  thorax  while  holding  his  breath,  can  force  down  the  food,  the 
deglutition  of  solid  food  becomes  more  and  more  difficult,  and  finally, 
only  liquids  can  be  taken.  Emaciation  may  become  quite  marked,  and 
after  several  years  atonic  dilatation  of  the  esophagus  may  result  similar 
in  character  to  atonic  gastric  dilatation  from  pyloric  spasm.  Dilatation 
of  the  esophagus  may  also  be  produced  by  benign  or  malignant  stenosis 
at  the  cardia;  or  by  paralysis  of  the  dilator  nerves  of  the  cardia,  from 
paralysis  of  the  esophagus,  or  by  loss  of  reflex  relaxation  of  the  cardia 
(Einhorn). 

Diagnosis. — In  acute  cases  the  existence  of  pain  and  dysphagia,  the 
delay  or  absence  of  the  swallowing  sound,  and  the  spasmodic  resistance 
at  the  cardia  on  insertion  of  the  stomach-tube,  which  can  be  overcome 
by  pressure,  together  with  the  presence  of  neurasthenia  or  hysteria, 
settle  the  diagnosis. 

In  the  chronic  type  the  history  of  the  case,  the  fact  that  often  the 
resistance  to  the  large  tube  is  less  than  to  the  small  one  in  nervous  cases,  all 
aid  the  diagnosis.     Dilatation  of  the  esophagus  may  finally  result. 

In  true  stenosis  (organic  stricture)  the  small  sounds  are  more  readily 
passed.  The  method  of  determining  esophageal  stricture  has  been 
described.  If  blood  appears  with  the  sound,  ulceration  is  at  once 
suggested.  Cachexia  is  suggestive  of  malignancy,  and  aspiration  of  the 
gastric  contents  will  settle  the  question.  Dilatation  of  the  esophagus 
occurring  as  a  result  of  cardiospasm  can  be  further  determined  as  follows : 

A  slice  of  bread  can  be  dissolved  in  200  c.c.  of  water  to  form  a  soft 
mass,  and  administered,  the  patient  being  instructed  to  employ  forcing 
movements,  so  that  it  will  enter  the  stomach.  An  hour  later  200  c.c.  of 
water  may  be  given,  no  forcing  movements  to  be  employed.  In  about 
three  to  five  minutes  an  aspirating  tube  can  be  passed  to  the  cardia,  a"nd 
if  dilatation  and  spasm  exist  the  water  just  ingested  can  be  removed,  and 
will  be  in  the  same  condition  as  taken.  The  tube  should  then  be  forced 
on  into  the  stomach  and  the  true  gastric  contents  removed.  These  are 
tested.  The  administration  of  barium  or  bismuth  with  the  employ- 
ment of  the  x-rays  is  also  of  value  for  the  purpose  of  diagnosis  of  dilata- 
tion of  the  esophagus.  Plummer's  method  for  determination  of  stenosis 
of  the  esophagus  is  described  under  that  subject. 

Prognosis  is  good  in  the  acute  cases,  but  as  regards  complete  cure  in 
chronic  cases  it  is  not  so  good,  though  there  is  no  danger  to  life,  as  a  rule, 
except  in  cases  with  marked  dilatation  of  the  esophagus. 

Treatment. — If  the  spasm  occurs  while  eating  and  drinking,  they 
should  be  performed  slowly.  The  food  should  be  well  masticated  or 
should  be,  preferably,  soft  in  character;  and  excessively  hot  or  cold  food, 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  487 

rich,  spiced  food,  etc.,  should  be  avoided.  Nutritive  enemata  to  rest  the 
esophagus  may  temporarily  be  required. 

General  tonics  should  he  given.  The  employment  of  sounds,  left  in 
place  for  some  time,  is  of  value. 

Tincture  of  belladonna,  10  minims  (0.592)  or  atropine,  gr.  Hoo  to  J^o> 
should  be  given  t.i.d.  to  relieve  spasm.  Anesthesin,  5  grains  (0.3)  t.i.d., 
relieves  pain.  The  bromids  are  of  service;  thus,  sodium  bromid,  15  to 
30  grains  (1.0-2.0)  t.i.d. 

Opium  or  chloral  should  be  administered  with  caution,  or  not  at  all. 

In  the  chronic  cases  soft  or  liquid  food  should  be  given.  The  patient 
should  bear  down  to  force  the  food  thoroughly  by  the  obstruction.  Olive 
oil,  I  to  4  drams  t.i.d.  before  food,  is  of  value.  The  stomach-tube  should 
be  introduced  at  least  once  a  day  to  relax  the  cardia;  if  there  is  emaciation, 
food  can  be  administered  through  the  tube;  if  the  esophagus  is  dilated,  it 
can  be  emptied  and  washed  out.  Dilatation  of  the  cardia  may  be  neces- 
sary. There  are  numerous  inflatable  bags  and  metal  dilators  (Einhorn's,^ 
for  example)  devised  for  this  purpose.  For  severe  cases  the  writer  prefers 
Plummer's  method  with  olives,  or  a  Stomach-tube  with  the  thread  guide, 
as  already  described.  He  also  has  an  inflatable  rubber  dilator,  which 
can  be  guided  by  the  same  method.  Rectal  feeding  must  be  enjoined  for 
a  time  in  severe  cases.     As  improvement  occurs  the  diet  can  be  increased. 

Surgery. — In  some  cases  gastrostomy  with  temporary  feeding  through 
the  opening  may  be  required. 

Insufficiency  of  the  Cardia 

Under  this  we  may  classify  eructation,  singultus,  pyrosis,  regurgitation, 
and  rumination. 

Eructation  (Belching). — Eructation  may  be  defined  as  the  expulsion 
of  gas  from  the  stomach  through  the  mouth. 

The  condition  may  be  secondary  to  various  affections  of  the  stomach 
and  intestines,  or  may  be  a  primary  neurosis. 

Normal  healthy  subjects  may  eructate  after  drinking  carbonated 
water,  or  those  who  eat  rapidly  without  proper  mastication,  and  thus 
swallow  considerable  air. 

Secondary  Cases. — Belching  may  be  associated  with  acute  or  chronic 
gastritis,  hyperacidity,  carcinoma  of  the  stomach  or  with  fermentative 
processes  in  the  stomach. 

The  clinical  symptoms,  gastric  analysis,  and  fermentation  test  will 
render  a  positive  diagnosis. 

In  fermentative  processes  the  gas  is  often  malodorous. 

Primary  Cases. — Nervous  Belching  (Eructatio  Nervosa)  and  Aerophagy. 
— We  have  cases  in  which  belching  occurs  at  short  intervals,  which  is 
independent  of  the  character  of  the  food  and  usually  of  nervous  origin. 
It  is  noisy,  as  a  rule,  and  may  persist  for  a  considerable  period  or  occur 
in  paroxysms. 

The  gas  consists  of  atmospheric  air  which  has  been  swallowed  (aero- 
phagia)  or  aspirated  into  the  stomach.  Aerophagy  is  sometimes  found 
'  Amer.  Jour.  Med.  Sci.,  Oct.,  1910. 


488  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

as  an  accompaniment  of  various  gastro-intestinal  diseases  and  believing 
the  discomfort  due  to  gas  and  in  endeavoring  to  eructate  by  swallowing, 
the  patients  actually  force  air  into  the  esophagus  and  swallow  it,  actually- 
becoming  aerophagics  without  knowing  it.  It  may  also  result  from  gum- 
chewing  or  from  swallowing  mucus  from  a  retro-pharyngeal  catarrh. 

Osier  claims  that  the  stomach  acts  as  an  elastic  sac,  and  can  aspirate 
the  air  without  the  effort  at  swallowing,  and  that  it  tends  to  fill  after 
expulsion.  Some  of  the  air  probably  comes  from  the  esophagus  and  has 
been  swallowed  just  previous  to  the  act  of  belching.  Bouveret  considers 
it  due  to  spasm  of  the  pharynx. 

Etiology. — This  nervous  type  of  eructation  is  observed  in  hysteric 
women  and  chiefly  in  neurasthenics,  or  after  excitement,  shock,  or  mental 
worry.     It  frequently  occurs  in  children,  often  in  several  of  a  family. 

Sjnnptoms. — The  belching  may  last  for  a  long  period,  only  occur 
during  the  day,  and  may  be  extremely  annoying.  Some  patients  may  not 
readily  relieve  themselves  by  belching,  and  the  air  thus  swallowed  may  be 
retained,  causing  a  balloon  stomach.  The  distention  may  even  become 
so  great  as  to  produce  acute  dilatation.  Regurgitation  may  occur  with 
the  belching  and  they  complain  of  digestive  disturbances.  The  air  may 
escape  into  the  small  intestines  and  distend  them  or  pass  into  the  colon. 

When  marked  distention  of  the  stomach  occurs,  there  may  be  dyspnea, 
tachycardia,  arrhythmias  or  cyanosis — all  of  which  are  relieved  by  passage 
of  the  stomach-tube. 

Diagnosis. — Absence  of  fermentation,  as  shown  by  the  test,  the  history 
of  nervousness  or  of  shock,  and  the  gastric  analysis  showing  normal  secre- 
tion, render  the  diagnosis  conclusive  in  the  nervous  cases. 

Treatment. — The  mouth  should  be  kept  open  when  belching,  to  pre- 
vent further  air  swallowing.  Massage,  hydrotherapy,  iron,  arsenic, 
bromides  and  belladonna,  change  of  climate,  the  faradic  current  (extra- 
ventricular  or  intragastric),  hydrotherapy  and  suggestion  to  the  patient 
are  of  service. 

In  cases  in  which  aeropkagy  complicates  other  gastric  conditions, 
acids,  or  alkalis  as  required  or  lavage  if  there  is  chronic  gastritis,  are  indi- 
cated. When  there  is  acute  distention  from  aerophagy  with  no  relief 
by  belching,  the  stomach-tube  is  indicated. 

Singultus  Gastricus  Nerrosus 

Singultus  or  hiccough  may  last  for  a  few  minutes,  several  hours,  or 
even  for  some  days.  It  may  cease  and  then  recur.  Hiccough  has  even 
resulted  in  a  fatal  issue,  the  patient  dying  of  exhaustion. 

Etiology. — Among  the  various  causes  are  diseases  of  the  viscera,  such 
as  gastritis,  hyperchlorhydria,  atony  of  the  stomach,  acute  or  chronic 
ectasy,  carcinoma  of  the  stomach,  catarrh  of  the  intestines,  intestinal 
obstruction,  peritonitis,  appendicitis,  intestinal  paresis,  pancreatitis,  dis- 
eases of  the  liver,  typhoid  fever,  pulmonary  disease,  alcoholism,  anesthesia, 
diabetes,  gout,  nephritis;  diseases  of  the  nervous  system,  such  as  epilepsy, 
meningitis,  brain  tumor,  etc.  It  is  often  one  of  the  terminal  symptoms 
as  death  approaches.     It  may  frequently  occur  with  hysteria. 


NERVOUS    AFFECTIONS    OF   THE    STOMACH  489 

As  a  pure  neurosis  it  is  an  extremely  rare  condition,  though  I  agree  with 
Bassler^  that  it  may  occur,  though  associated  with  hyperesthesia  of  the 
stomach  or  with  gastralgia.  It  must  be  diagnosed  by  the  process  of  ex- 
clusion and  I  beHeve  most  of  the  so-called  cases  of  singultus  gastricus 
nervosus  are  really  a  symptom  of  the  hysterical  condition. 

Treatment. — The  gastric  functions  must  be  examined  in  all  cases  and 
functional  disturbances  corrected.  Iron,  arsenic,  sodium  bromid,  strychnin, 
and,  at  times,  belladonna  are  indicated.  The  general  nervous  condition 
of  the  patient  must  be  treated  and  the  physical  condition  improved. 
During  a  severe  attack,  inhalation  of  amyl  nitrite  will  at  times  be  beneficial. 

Pyrosis  (Heart-burn) 

This  consists  in  the  ejection  of  chyme  from  the  stomach  into  the  esopha- 
gus, with  which  is  associated  a  burning  sensation  in  the  epigastrium. 

Etiology. — As  a  symptom  it  most  frequently  occurs  with  hyperchlor- 
hydria,  also  with  chronic  gastritis,  and  has  been  found  with  achylia  and 
other  gastric  conditions. 

It  may  occur  as  a  neurosis,  especially  among  the  hysteric  or  neuras- 
thenic, with  normal  gastric  contents,  and  is  of  mixed  type,  both  motor  and 
sensory. 

General  tonics  and  electricity  are  of  value  in  the  nervous  cases. 

If  hyperacidity,  chronic  gastritis,  achylia,  or  other  gastric  disturbances 
are  present,  they  should  receive  appropriate  treatment  as  being  the 
primary  cause  of  the  pyrosis.  Sodium  citrate  acts  as  an  alkali  and  is  of 
value  in  many  cases  of  pyrosis. 

Regurgitation 

Regurgitation  denotes  the  condition  in  which,  after  eating,  some  of  the 
food  ingested,  liquid  or  liquid  and  solid,  rises  from  the  stomach,  enters 
the  mouth,  and  is  ejected. 

Occasionally,  small  fragments  are  swallowed  again.  The  act  is  usually 
involuntary,  though  it  can  be  produced  by  some  at  will.  Early  regurgi- 
tation tastes  of  the  food,  later  it  is  acid.  The  patients  can  suppress  it  at 
will,  and  in  this  way  it  differs  from  regurgitation  due  to  cardiac  stenosis 
or  diverticula. 

The  passage  of  the  esophageal  sound  or  olive,  and  chemic  analysis  also 
give  aid  in  diagnosis.  In  some  cases,  if  regurgitation  is  marked,  con- 
siderable emaciation  may  result. 

Organic  disease,  such  as  stricture  of  the  esophagus,  must  be  excluded; 
also  gastritis. 

Etiology. — Patients  of  nervous  or  hysteric  type  develop  this  condition; 
and  mental  worry  and  nervous  strain  may  be  the  cause. 

Prognosis  is  good. 

Treatment. — The  patient  should  eat  slowly  and  masticate  his  food. 
Treatment  by  "suggestion"  is  good;  also  forbid  the  patient  to  spit  out 
his  food,  and  tell  him  to  swallow  it  again. 

'  N.  Y.  Med.  Jour.,  Aug.  13,  1910. 


490  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Massage,  faradization  (intragastric  and  extragastric) ;  strychnin,  }4o 
grain  (0.0016)  t.i.d.,  and  the  treatment  of  the  nervous  condition  are 
indicated. 

Riunination 

(Synonym. — Merycism,  "Chewing  the  cud") 

In  this  condition  the  food  is  returned  from  the  stomach,  without  nau- 
sea, into  the  mouth,  some  time  after  meals,  where  it  is  chewed  and  swal- 
lowed again. 

Etiology. — It  occurs  more  frequently  in  men  than  in  women;  and  most 
of  the  cases  reported  belong  to  the  higher  classes,  especially  among  pro- 
fessional men. 

Many  of  the  lower  class  would  not  deem  the  condition  abnormal,  and 
women  would  conceal  it,  so  it  may  be  said  to  belong  to  all  classes.  It 
occurs  among  hysteric  persons,  neurasthenics,  epileptics,  and  idiots. 

Possibly  heredity  and,  undoubtedly,  imitation  in  many  cases  are  fac- 
tors. Occasionally  there  may  be  a  pathologic  condition  of  the  stomach, 
with  regurgitation,  and  rumination  follows.  Several  cases  have  been 
reported  of  imitation  among  children. 

Shock,  trauma,  rapid  eating,  and  emotional  disturbances  in  nervous 
persons  are  at  times  accessory  factors. 

Gastric  Findings. — In  some  cases  hyperacidity  has  been  found,  and 
ruiiiination  diminished  after  this  was  corrected. 

Diminished  acidity  has  been  found  by  Boas,  and  improvement  fol- 
lowed after  hydrochloric  acid  was  administered. 

On  the  other  hand,  achylia  gastrica  has  been  present  in  such  cases 
and  also  normal  secretion. 

The  motor  functions  are  nomaly  in  most  cases. 

Prognosis. — The  habit  may  be  corrected  in  part,  but  may  persist  for 
years,  with  no  impairment  of  health.  In  some  patients  the  attacks  are 
periodic. 

Treatment. — Any  secretory  anomaly  that  exists  must  be  corrected. 
The  treatment  should  be  by  mental  impression  (psychic)  on  the  part  of 
the  physician.  The  patient  should  be  taught  that  he  can  readily  suppress 
the  condition.  Small  bits  of  ice  after  meals,  lavage,  and  gavage  have 
been  suggested.  The  bromids  may  be  of  service.  The  nervousness 
should  be  corrected  by  iron,  strychnin,  and  arsenic. 

G.  Variot^  reports  a  case  in  which  after  failure  of  dieting  and  other 
remedies  he  secured  improvement  by  the  use  of  sodium  citrate,  3i  to  5iss 
given  daily  in  divided  doses  in  water  before  meals.  The  use  of  one  glass 
of  water  to  which  the  juice  of  half  a  lemon  and  a.  "^i  oi  sodium  bicarbonate 
was  added,  exercised  a  sedative  action  in  another  case. 

Nervous  Vomiting  (Vomitus  Nervosa) 

Vomiting  is  a  complex  process.     There  is  a  contraction  of  the  ab- 
dominal muscles  and  fixation  of  the  diaphragm,  with  a  contraction  of  the 
stomach,  accompanied  by  closure  of  the  pylorus  and  opening  of  the  cardia; 
^  Bulletin  at  Memoires  de  la  Society  medicule  des  Hdpitaux  de  Paris,  May  i,  1913. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  49I 

reversed  peristalsis  of  the  esophagus  and  closure  of  the  larynx  and  posterior 
nares  occur,  with  resulting  expulsion  of  the  stomach-contents  through  the 
mouth.     The  vomiting  center  lies  in  the  medulla  near  the  vagus  center. 

Vomiting  may  be  due  to  some  organic  disease  of  the  stomach  or  as  a 
result  of  irritation  due  to  the  ingestion  of  food  of  abnormal  character. 
Certain  intoxications,  as  from  uremia,  cholemia,  opium,  morphin,  tobacco, 
ether,  or  chloroform,  may  produce  vomiting. 

Nervous  vomiting  is  characterized  by  the  absence  of  these  conditions 
just  mentioned,  and  may  be  either  cerebral  or  spinal  in  origin,  or  due 
to  reflex  disturbance,  overexertion,  emotional  shock,  anger,  fright,  or 
neurasthenia. 

Among  the  cerebral  causes  are  organic  disease  of  the  brain  and  its 
meningesj  concussion,  and  tumors. 

Spinal  forms,  such  as  tabes,  or  occasionally  paresis,  multiple  sclerosis, 
and  subacute  myelitis. 

Reflex  causes,  such  as  from  the  pharynx,  larynx,  palate,  liver,  peri- 
toneum, kidneys,  genitals,  etc.  Juvenile  vomiting  and  the  periodic  or 
cyclic  vomiting  (Leyden),  also  the  cyclic  vomiting  of  children  (infants) 
are  included. 

Characteristics  of  Nervous  Vomiting. — Stiller  calls  attention  to  the 
following  peculiarities: 

This  type  of  vomiting  seems  to  be  independent  of  the  character  and 
quality  of  the  food,  and  occurs  generally  without  any  premonitory  symptoms. 
Sometimes  digestible  foods  are  vomited,  while  indigestible  material  is 
well  borne.  There  seems  at  times  to  be  power  of  selection  to  vomit  cer- 
tain nutriment,  and  the  patients  suffer  from  no  inanition.  Vomiting  may 
also  occur  from  the  empty  stomach,  and  the  condition  is  associated  with 
various  nervous  symptoms. 

Boas  has  noted  that  the  motor  and  secretory  functions  are  normal, 
though  Bouveret  and  Einhorn  have  observed  a  diminution  or  absence  of 
secretory  function  in  some  cases. 

Treatment. — Tonics.  Correct  disturbance  of  secretory  functions. 
Mental  impression  on  the  part  of  the  physician  is  important.  Change 
of  scene  is  at  times  of  value.  Rosenhaubt  recommends  anesthesin  t.i.d, 
ten  minutes  before  meals  given  in  a  2  to  3  per  cent,  strength  in  a  given 
mixture,  of  which  the  dOse  is  one  teaspoon. 

PERIODIC  VOMITING  (VON  LEYDEN) 

There  are  several  peculiarities  connected  with  this  type  of  vomiting. 
As  a  rule,  no  caiise  can  be  discovered,  and  the  attack  appears  when  the 
patient  is  in  perfect  health.  The  attacks  occur  at  intervals  of  equal 
duration.  After  the  attack  the  patient  is  immediately  restored  to  health, 
and  remains  well  until  the  next  one  occurs. 

They  resemble  somewhat  the  gastric  crises  of  tabes,  and  are  similar 
in  suddenness  of  occurrence  to  violent  attacks  of  migraine.  They  seem  to 
be  influenced  by  emotional  disturbances.  They  begin  with  slight  nausea 
and  with  a  chilly  feeling  and  headache,  followed  by  vomiting  of  the  gas- 
tric contents,  and,  later,  bile  and  mucus  streaked  with  blood.  Lerche^ 
^  Med.  Rec,  April  30,  1910. 


492  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

reports  a  case  in  which  the  patient  vomited  from  a  few  tablespoons  to  a 
cupful  of  blood  during  each  attack. 

The  vomiting  is  very  persistent,  and  all  food  or  even  small  quantities 
of  water  are  ejected.  In  some  cases  there  is  severe  pain.  The  patient 
becomes  greatly  prostrated,  the  abdomen  sunken,  and  the  face  pale.  The 
attack  may  last  from  a  day  to  a  week  or  longer.  Suddenly  the  nausea 
and  vomiting  cease,  the  appetite  returns,  and  the  patient  is  rapidly  re- 
stored to  health. 

Gastric  Juice. — This  has  been  found  to  he  normal  in  most  cases,  though 
Einhorn  reports  a  case  of  achylia  gastrica.  On  the  other  hand,  with 
gastrosuccorrhea,  the  content  of  hydrochloric  acid  is  high,  a  valuable  aid 
to  differential  diagnosis. 

Treatment. — ^Rest,  ice  pellets,  morphin,  }i  grain  (0.016),  by  hypo- 
dermic, and  belladonna  tincture,  10  minims  (0.59),  are  useful.  Cocain 
I  deprecate.  Tincture  of  hyoscyamus,  30  drops  (2  c.c),  and  hot  applica- 
tions during  attacks.  Oxalate  of  cerium  in  grain  doses  is  of  value.  Be- 
tween attacks,  tonics,  change  of  climate,  and  hydrotherapy.  Avoid 
opiates  as  far  as  possible. 

Cyclic,  Recurrent,  or  Periodic  Vomiting  in  Children 

This  is  probably  due  to  faulty  metabohsm  (auto-intoxication) ;  occurs 
generally  in  those  from  two  to  four  years  of  age,  of  a  nervous  type  and 
rheumatic  diathesis  (the  rheumatic  complex). 

Etiology. — Kerley^  shows  that  these  children  belong  to  the  class  known 
as  "the  rheumatic  complex"  suffering  frequently  in  addition  to  cyclic 
vomiting  from  habit  spasm,  chorea,  recurrent  spasmodic  croup  and  spas- 
modic bronchitis.  They  have  growing  pains  and  are  subject  to  rhinitis, 
tonsillitis,  acute  rheumatism  and  endocarditis.  The  fats  and  sugar  have 
a  deleterious  effect. 

These  cases  represent  defective  oxidation  with  the  liver  probably  at 
fault.  Habitual  constipation  may  precipitate  an  attack,  or  fright  or  fatigue. 
When  elimination  is  better  and  open-air  exercise  is  possible  as  in  late 
spring,  summer  and  early  fall,  there  are  fewer  attacks. 

Griffith^  holds  that  cyclic  vomiting  may  give  symptoms  very  similar 
to  appendicitis,  the  absence  of  signs  of  local  inflammation  being  the  chief 
differential  point. 

Russell^  reports  a  case  of  cyclic  vomiting  which  autopsy  apparently 
showed  was  due  to  recurrent  spasm  in  an  hypertrophied  and  somewhat 
stenosed  pylorus. 

Comby^  believes  that  cyclic  vomiting  is  generally  due  to  chronic 
appendicitis  and  that  cures  have  followed  in  many  cases  as  a  result  of 
appendectomy. 

Symptoms. — There  are  rarely  premonitory  symptoms  such  as  loss  of  ap- 
petite, foul  breath  or  a  yellow  tint;  temperature  is  but  seldom  over  ioo.5°F. 
though  it  may  not  occur.     It  may  even  be  subnormal;  anorexia,  nausea, 

1  Practice  of  Pediatrics. 

'  Amer.  Jour.  Med.  Sci.,  cxx,  p.  553. 

^  Brit.  Jour,  of  Children's  Diseases,  Feb.,  1910. 

*  Archiv  f.  Kinderheilkunde,  vol.  1,  1909,  p.  33. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  493 

languor,  followed  by  persistent  and  violent  vomiting  of  food,  mucus 
streaked  with  blood  occasionally  and  at  times  bile.  Prostration  is  marked ; 
the  gastric  contents  very  acid;  occasionally  large  amounts  of  blood  are 
vomited.  The  child  becomes  pale,  eyes  sunken,  and  loss  of  weight  marked. 
Acetone,  diacetic  acid,  and  oxybutyric  acid  are  present  in  the  urine,  and 
so  it  is  believed  it  is  a  form  of  acid  intoxication;  others  consider  the  acidosis 
a  result  of  the  condition;  uric  acid  in  the  urine  is  diminished.  Breath  has 
odor  of  acetone.  The  attack  may  last  a  few  hours  but  usually  three  to 
five  days.  It  is  a  lithemic  manifestation.  The  attacks  are  periodic  and 
rapid  recovery  from  each  ensues. 

The  attack  resembles  migraine  in  the  adult.  Antecedents  are  a 
neurotic  and  gouty  family  history.  Carbohydrates  in  excess  some  be- 
lieve have  a  bearing  on  its  production,  but  fats  and  sugar  are  thought  to 
be  responsible.     Fatigue,  excitement,  or  tonsillitis  bring  it  on. 

Prognosis. — Good. 

Diagnosis. — Attacks  are  not  precipitated  by  indigestible  food  but  by 
fats  and  sugar;  the  disease  is  self-limited,  and  the  child  rapidly  returns 
to  the  normal  state.     The  attacks  are  repeated. 

Treatment. — Calomel  to  abort  it;  food  and  drink  should  be  stopped; 
enemata  and  enteroclysis  are  advisable.  Hypodermoclysis  or  procto- 
clysis for  thirst  and  fluid  loss  may  be  necessary  in  severe  cases  and  rectal 
feeding  is  indicated. 

For  Acute  Attack. — Alkaline  Treatment. — Sodium  bicarbonate,  15-  to 
30-grain  (1.0-2.0)  doses,  may  be  given  t.i.d.  by  mouth,  or  double  dose  by 
rectum  even  to  5ii  every  six  to  eight  hours  in  5vi-5viii  water  if  neces- 
sary for  the  acidosis.  Small  amounts  of  strained  oatmeal  gruel  or  white 
of  egg  may  be  given  at  this  time. 

Heat  should  be  applied  over  the  abdomen  and  perfect  quiet  enjoined. 
Small  doses  of  cerium  oxalate,  gr.  34-K>  three  or  four  times  a  day  can  be 
given. 

Medication  and  Diet  between  Attacks. — Kerley  advises  the  following 
medication  and  general  diet,  which  I  believe  excellent.  For  a  child  three 
to  ten  years,  9  to  la  drops  oil  wintergreen  or  salicylate  of  soda,  or  aspirin 
total  9  to  12  grs.  per  diem  after  meals,  in  divided  doses  (j.g.,3to4grs.  ata 
dose)  for  five  days  out  of  fifteen.  During  the  other  ten  days  gr.  10  soda 
bicarbonate  twice  daily  after  meals  and  so  on  for  months.  Aspirin  is 
excellent  if  the  salicylates  disagree.  The  child  should  have  regular  meals 
and  rest  a  short  period  thereafter.  The  bowels  must  be  kept  regular  by 
means  of  green  vegetables  and  fruit,  avoiding  enemata. 

These  children  should  not  take /a/,  or  sugar,  or  cane  sugar ,  nor  cow^ s  milk 
fat.  Cream  and  raw  fruit,  especially  highly  acid  fruit  are  excluded.  Red 
meat  is  given  sparingly  (only  occasionally).  Yolks  of  eggs  are  prohibited. 
Sugar  is  absolutely  excluded  and  deserts  and  stewed  fruits  are  flavored  with 
saccharin.  Poultry,  fish  and  egg  whites  are  allowed.  Skimmed  milk  or 
buttermilk  may  be  given  A.  M.  and  P.  M.  Among  the  cereals  allowed  are 
cornmeal,  oatmeal,  hominy,  rice,  farina  and  cream  of  wheat  served  with 
a  little  butter  and  salt  or  skimmed  milk.  The  child  may  take  occasionally 
a  baked  potato,  also  carrots,  squash,  cauliflower,  turnip,  asparagus  tips, 


494  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

purees  of  peas  or  beans,  custard  made  with  whites  of  eggs,  saccharin  and 
skimmed  milk  flavored  with  vanilla,  cornstarch,  junket,  or  rice  pudding. 

'^.  Sodii  bicarb 3"; 

Fl.  ext.  cascara  aromatic, 

Syrup  rhei aa   gii. 

Sig. — One-half  to  one  teaspoon  after  each  meal  for  constipation. 


Juvenile  Vomiting 

Overwork  at  school  is  often  the  cause.     Cardialgia  and  vomiting  occur. 
There  may  be  headache,  slow  pulse,  pallor,  dilatation  of  pupils,  etc. 
Treatment.- — ^Tonics,  proper  diet,  removal  from  school. 

Reflex  Vomiting 

Nervous  vomiting  is  frequently  reflex  in  character  from  disease  of 
almost  any  organ.  Among  the  causes  are  disease  of  the  pharynx,  elon- 
gated uvula,  diseases  of  the  abdominal  organs,  as  hydronephrosis,  movable 
kidney,  kidney  colic,  ptosis  of  the  liver  or  spleen,  peritonitis,  appendicitis, 
hernia,  cerebral  disease  and  disease  of  the  sexual  organs.  These  condi- 
tions should  receive  appropriate  treatment. 

The  vomiting  of  pregnancy  belongs  to  this  type. 

Belladonna  tincture,  lo  minims  (0.59),  t.i.d.;  cerium  oxalate,  2  grains 
(0.13),  t.i.d.;  Fowler's  solution  of  arsenic,  several  doses  i  drop  each; 
bromids,  15  grains  (i.o);  codein,  1^  grain  (0.016);  or  chloral,  3  grains 
(0.194),  t.i.d. 

I^.  Menthol gr.  x  (o. 6); 

Syrup 5ij  (60.0); 

Aq.  destil q.  s.  5iv  (125.0). — M. 

Sig. — Two  teaspoonfuls  t.i.d. 

The  use  of  cocain  I  deprecate.    Lavage  is  temporarily  of  service. 
Abortion  may  occasionally  be  required  in  pregnancy  cases.     Change 
of  scene  may  be  necessary. 

Idiopathic  Nervous  Vomiting 

In  some  hysteric  or  neurasthenic  persons  (adults)  vomiting  will  occur 
after  meals  without  any  apparent  cause,  more  frequently  in  women  and 
without  showing  the  periodic  type.  Usually  part  of  the  meal  is  vomited. 
It  may  continue  for  a  long  period.  Nutrition  is  frequently  not  disturbed. 
The  vomiting  may  occur  so  quickly  during  the  act  of  ingestion  of  food  that 
it  seems  as  if  it  did  not  enter  the  stomach,  but  was  rejected  by  the  esoph- 
agus.    Other  patients  seem  normal  in  this  regard. 

Occasionally  hysteric  subjects  may  vomit  blood.  In  all  cases  the 
gastric  secretion  must  be  studied,  so  as  to  exclude  hyperchlorhydria, 
hypersecretion,  etc.,  and  to  observe  whether  vomiting  complicates  some 
other  disease  or  is  a  reflex  afiFection. 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  495 

Treatment. — Suggestion  by  the  physician,  the  regulation  of  the  mode 
of  life,  tonics,  such  as  arsenic  and  iron,  bromids;  change  of  climate;  gavage 
for  about  two  weeks;  lavage,  with  i  :  looo  nitrate  of  silver,  has  proved 
of  value. 

Faradization,  extra-abdominal  or  intragastric,  has  been  of  benefit. 

Pneumatosis 

Spasm  of  the  cardia,  combined  with  pyloric  spasm,  may  produce 
pneumatosis  (distention  of  the  stomach  with  air),  with  a  resulting  sensa- 
tion of  tension  and  at  times  dyspeptic  asthma. 

Hysteric  or  neurasthenic  symptoms  are  associated. 

Aerophagia  (air  swallowing)  is  probably  the  cause,  and  to  the  section 
on  such  the  reader  should  also  refer.  The  upper  part  of  the  abdomen  is 
markedly  distended  and  tympanitic,  and  there  is  interference  with  res- 
piration.    As  a  rule,  there  is  no  belching. 

Diagnosis. — Organic  affections  of  the  stomach  must  be  excluded,  in 
which  the  gas  has  a  foul  odor  and  the  contents  ferment. 

Treatment. — Tonics  and  bromids  are  indicated.  Aspiration  of  the 
stomach  in  the  acute  attack,  so  as  to  give  exit  to  the  air,  is  the  best  method. 
It  may  be  necessary  to  repeat  it. 

Extract  physostigmatis,  }i  grain  (0.008),  or  eserin,  Hoo  grain  (0.00065) 
or  morphin,  }i  grain  (0.016),  or  tincture  of  belladonna,  10  minims  (0.59), 
or  extract  of  belladonna,  K  grain  (0.016),  may  be  required.  A  little  pep- 
permint water  or  spirits  of  chloroform  aid  the  belching  of  gas. 

SECRETORY  NEUROSES 

The  secretory  function  of  the  stomach  is  undoubtedly  under  the  direct 
control  of  the  nervous  system.  For  example,  in  a  hungry  dog  with  a 
fistula  the  sight  of  meat  will  produce  gastric  secretion,  and  in  the  case  of 
a  man  with  impermeable  esophagus,  but  with  a  gastric  fistula,  mastication 
produced  gastric  secretion.  The  vagus  has  been  demonstrated  to  be  the 
secretory  nerve.  The  stomach  itself,  however,  possesses  some  secretory 
power  since  after  section  of  the  pneiimo gastric  afid  sympathetic  nerves, 
secretion  will  occur  after  the  application  of  an  irritant. 

Hyperchlorhydria,  gastrosuccorrhea  (hypersecretion),  and  achylia 
gastrica  may  all  be  functional  disorders  of  secretion,  and  have  been  de- 
scribed in  special  chapters. 

Subacidity  (hyposecretion,  hypochylia  gastrica,  hypochlorhydria)  may 
be  of  nervous  origin,  and  must  be  differentiated  from  cases  occurring  with 
organic  disease  of  the  stomach,  especially  gastric  catarrh. 

Hydrochloric  acid,  strychnin,  massage,  and  electricity  are  of  service  in 
these  last  cases. 

In  the  subacid  cases  sudden  changes  in  the  gastric  findings  (secretory) 
are  in  favor  of  a  neurosis. 

Disorders  of  secretion  may  accompany  other  diseases,  such  as  tabes  or 
spinal  lesions. 


496  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

NERVOUS  DYSPEPSIA  (LEDBE) 
(Synonym. — Neurasthenia   Gastrica) 

Leube  originally  described  nervous  dyspepsia  as  a  disorder  of  the 
stomach,  characterized  by  a  variety  of  distressing  subjective  symptoms 
during  the  act  of  digestion,  but  in  which  it  was  normal  as  regards  time  and 
chemism.  In  eflFect,  he  originally  considered  "nervous  dyspepsia"  as  a 
neurosis  of  sensibility.  He  has  more  recently  extended  his  definition  to 
other  forms.  Strictly  speaking,  nervous  dyspepsia  is  a  combined  gastric 
neurosis  in  which  the  sensory  disturbances  (subjective  symptoms)  are  the 
most  prominent. 

It  may  be  combined  with  secretory  and,  at  times,  even  with  motor 
disturbances. 

Gastric  Juice. — The  findings  in  the  gastric  juice  are  not  characteristic. 
It  may  be  frequently  normal;  it  may  occasionally  be  hyperacid,  more 
frequently  diminished  acidity,  or  at  times  there  may  be  variations  in  the 
same  subject.     In  long  persistent  cases  atony  may  be  present. 

Some  authors  refer  to  the  presence  of  enteroptosis  or  membranous  colitis 
with  neurasthenia  gastrica.  In  this  connection  it  is  evident  that  fre- 
quently the  diagnosis  of  "nervous  dyspepsia"  is  made,  when,  in  reality, 
gastroptosis  (enteroptosis)  is  the  basis  of  the  difficulty.  With  the  ptosis 
of  the  viscera  we  have  sensory,  secretory,  and  frequently  motor  dis- 
turbances of  the  stomach,  associated  with  nervous  symptoms,  but  the 
correction  of  the  ptosis  will  cure  the  condition. 

In  pure  nervous  dyspepsia  all  organic  lesions  of  the  stomach  must  be 
excluded,  and  also  ptosis  of  the  viscera.  The  stomach  must  occupy  the 
normal  position. 

Etiology. — Neurasthenia  gastrica  may  occasionally  appear  as  an 
independent  neurosis,  but  more  usually  with  nervous  symptoms,  hysteria, 
or  neurasthenia.  Grip,  pulmonary  disease,  anemia,  chlorosis,  malaria,  or 
debilitating  conditions  predispose  to  it,  as  do  also  reflex  irritation  from  the 
sexual  organs,  excessive  venery,  abuse  of  alcohol,  or  tobacco. 

Age  and  Sex. — This  disease  occurs  more  fequently  in  men  than  in 
women,  especially  among  brokers  and  those  subject  to  worry  and  mental 
strain,  and  usually  at  the  prime  of  life,  between  thirty  and  fifty,  though  it 
may  be  present  at  other  periods. 

Symptoms. — The  patient  generally  complains  of  a  feeling  of  fulness  or 
pressure  after  eating,  or  even  of  slight  pain  or  belching,  loss  or  irregularity 
of  appetite,  a  sleepy  feeling,  or  even  weakness  or  dizziness.  The  tongue  is 
usually  clean.  There  is  marked  mental  depression,  and  the  patients  are 
nervous  and  anxious.  One  peculiarity  is  that  the  quantity  and  quality  of  the 
food  seems  to  make  little  difference  in  their  symptoms.  At  times  indigestible 
food  can  be  taken  without  discomfort,  while  at  other  times  digestible  food 
may  produce  the  symptoms.  Occasionally  the  pain  and  discomfort  are 
present  when  the  stomach  is  empty.  There  is  often  nausea  and  occasion- 
ally vomiting.  Thirst  is  variable.  There  is  usually  tension  or  fulness 
of  the  intestines  due  to  accumulation  of  gas,  which  is  passed  later  per  rec- 
tum.    The  bowels,  as  a  rule,  are  constipated,  with  occasionally  an  alter- 


NERVOUS    AFFECTIONS    OF    THE    STOMACH  497 

nating  diarrhea.  The  movements  may  appear  in  narrow  cylindroids  or 
small  balls  in  some  cases. 

In  addition  to  the  feelings  of  depression,  insomnia,  palpitation,  head- 
ache, and  lassitude  may  be  present;  also,  vertigo,  impotence,  or  emissions. 

The  surroundings  and  general  mood  of  the  patient  have  a  marked  in- 
fluence on  the  symptoms.  The  cases  are  often  extremely  disagreeable  in 
their  "home  life."  Circumscribed  points,  sensitive  to  pressure,  have 
been  described  as  diagnostic;  one  below  the  ensiform  and  the  others  near 
the  navel,  especially  to  the  left,  but  Ewald  has  demonstrated  "nervous 
dyspepsia"  in  which  no  such  points  could  be  found. 

Course. — The  course  of  the  disease  is  slow  and  the  symptoms  vary; 
sometimes  one  symptom  being  prominent;  at  another  time,  another.  The 
mood  of  the  patient  has  a  marked  influence,  and  in  good  company  he  may 
forget  his  trouble.  They  generally  do  not  suffer  much  in  nutrition,  but  in 
cases  with  insomnia  they  at  times  lose  considerable  weight. 

Diagnosis. — The  presence  of  general  nervous  symptoms,  especially 
of  those  pointing  to  the  stomach,  without  the  presence  of  organic  disease  of 
the  organ;' the  fact  that  the  gastric  secretion  is  often  found  to  be  normal, 
though  at  times  hypochlorhydria  and  more  rarely  a  mild  hyperchlor- 
hydria,  and  that  we  frequently  obtain  variable  gastric  analyses  in  the  same 
patient;  that  there  is  lack  of  proportion  between  the  gastric  findings  and 
the  condition  of  the  digestive  organs,  as  compared  with  the  severe  com- 
plaints voiced  by  the  patient;  that  the  character  of  the  food,  whether 
digestible  or  indigestible,  seems  to  make  no  difference  as  regards  increasing 
or  ameliorating  the  symptoms,  and,  finally,  that  change  of  scene  or  the 
mental  condition  of  the  patient  has  a  decided  influence  on  the  condition — 
all  these  facts  point  to  neurasthenia  gastrica.  The  writer  believes  pure 
nervous  dyspepsia  to  be  rare,  and  that  it  is  often  thus  incorrectly  diagnosed. 

Differential  Diagnosis. — The  chief  differences  are  as  follows: 

Neurasthenia  Gastrica. — Character  of  the  food  makes  no  difference  as  to 
symptoms.  There  are  sudden  changes  in  the  patient's  condition:  well  for 
a  few  days,  and  then  marked  symptoms;  nervous  symptoms  marked. 
Gastric  secretion  often  normal,  and  frequently  variable  in  the  same  patient 
at  different  times. 

Chronic  Gastritis. — Aggravated  by  errors  in  diet;  symptoms  constant; 
mucits  in  the  gastric  contents;  reduction  in  hydrochloric  acid  is  marked  as  a 
rule. 

Ulcer  of  the  Stomach. — Painful  area  in  the  epigastrium,  tender  on 
pressure;  dorsal  pain;  hematemesis  or  occult  blood,  melena,  and  pain  is 
increased  markedly  after  ingestion  of  food.  The  character  of  the  food 
influences  the  pain  markedly,  even  in  the  more  obscure  cases.  Pain 
remits  or  disappears.    Hyperacidity  in  some,  but  not  in  all. 

Cancer. — Age  of  patient  40-60  yrs.;  tumor,  cachexia;  quality  and  quan- 
tity of  the  food  may  not  markedly  influence  the  pain;  gastric  analysis 
usually  showing  absence  of  free  HCl,  lactic  acid,  and  Boas-Oppler  bacilli 
present;  pain  continuous;  progressive  emaciation. 

Treatment. — If  there  are  any  sexual  disorders  which  reflexly  might 
affect  the  nervous  condition,  these  should  be  treated;  sexual  excesses  or 
overindulgence  in  alcohol  or  tobacco  should  be  checked.  Brokers  and 
32 


498  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

professional  men  who  have  mentally  overexerted  themselves  or  are  tired 
mth  the  worry  of  business  cares,  lead  an  irregular  life,  or  who  are  engaged 
too  actively  in  social  pursuits,  if  possible,  should  have  a  change  of  scene. 
Horseback  riding,  walking,  golf,  yachting,  fishing,  shooting,  camp  life 
for  a  few  weeks,  a  pleasure  trip,  all  give  excellent  results.  A  short  ocean 
trip  south  or  abroad  is  of  service.  For  those  who  cannot  afford  these 
methods,  the  lightening  of  business  and  professional  cares  is  important. 

Hydrotherapy,  massage,  electricity,  especially  by  the  faradic  current, 
combined  with  out-of-door  life  and  proper  exercise,  mild  gymnastics,  so 
as  not  to  tire  the  patient,  are  of  value.  The  mental  impression  crea-ted 
by  the  physician  is  important.  Static  electricity  is  at  times  of  service. 
General  faradization,  the  bare  feet  on  one  electrode,  and  the  other  being 
passed  over  the  body,  is  useful  (Rockwell). 

The  diet  should  be  abundant,  the  patient  avoiding  highly  seasoned 
food,  alcohol,  strong  coffee,  and  excessive  smoking. 

Stomachics  should  be  given  if  hydrochloric  acid  is  deficient,  such  as  nux 
vomica,  compound  tincture  of  cinchona,  dilute  hydrochloric  acid,  etc. 

If  hyperchlorhydria,  then  the  alkalis  should  be  administered.  The 
patient  should  secure  the  proper  amount  of  sleep. 

Forced  feeding  and  the  Weir-Mitchell  rest  cure  are  necessary  in 
severe  cases.  Milk,  cream,  butter  and  raw  eggs  are  of  value  in  reduced 
nutrition. 

Malbranc's  gastric  douche  has  been  recommended  in  some  cases,  and 
Einhorn  suggests  the  use  of  his  gastric  spray.  Personally  I  do  not  employ 
such  local  measures. 

The  general  tone  of  the  patient  should  be  built  up  by  iron,  such  as 
iron  pills,  iron  tropon,  arsenic,  and  strychnin.  Small  doses  of  nux 
vomica,  combined  with  compound  tincture  of  cinchona,  are  excellent  to 
improve  the  appetite: 

I^.  Tr.  nucis  vomicae 3uj  (12.0); 

Comp.  tinct.  cinchona 5ss  (16.0); 

Aq.  destil q.  s.  giv  (125.0). — M. 

Sig. — I  to  2  teaspoonfuls  t.i.d.  in  water  before  meals. 

Basic  orexin,  3  grains  (2  decigrams)  t.i.d.,  has  also  been  recommended 
by  Einhorn  for  this  purpose. 

Sodium  or  ammonium  bromid,  5  to  10  grains  (0.3-0.6)  two  or  three 
times  a  day,  lessens  the  nervousness. 

The  bowels  should  be  properly  regulated  by  the  diet  and  by  cascara, 
aloin  pills,  phenolax,  regulin,  mineral  oils,  olive  oil,  etc.  Iron  springs,  such 
as  Franzensbad,  or  salines,  as  Kissengen  or  Weisbaden,  are  of  service. 

The  carbonated  bath  (Nauheim,  Triton)  I  have  found-^given  every 
other  day  at  home  for  a  course  of  12  baths  at  a  temperature  of  95°  to  98°F. 
— to  be  of  service  in  toning  up  the  circulation  and  general  nervous  condi- 
tion. 


CHAPTER  XVIII 
DYSPEPTIC  ASTHMA 

This  type  of  asthma,  due  to  digestive  disturbances,  was  first  described' 
by  Henoch,  ^  later  by  Silberman,^  Oppler,'  Boas,*  Murdoch,^  Einhom,* 
and  others. 

The  symptoms  first  reported  by  Henoch  were  of  an  acute  type,  and, 
according  to  his  belief,  were  the  result  of  reflex  action  starting  from  the 
stomach.  It  is  noteworthy  that  the  most  severe  symptom  disappeared 
when  the  patient  vomited.  In  his  cases  the  breathing  was  rapid  and  shallow, 
pulse  rapid  and  feeble,  and  at  times  so  rapid  that  it  could  not  be  counted, 
extremities  cool,  the  temperature  subnormal,  and  there  were  even  symp- 
toms of  collapse. 

In  all  cases  there  was  acute  dyspepsia  due  to  some  error  in  diet.  The 
region  of  the  stomach  was  usually  distended  and  painful.  The  greatest 
number  of  cases  were  observed  in  children.  Numerous  explanations  have 
been  given  for  this  condition,  and  a  variety  of  experiments  have  been 
performed.  Henoch  believes  it  to  be  due  to  reflex  action,  starting  from 
the  stomach  and  causing  a  vasomotor  spasm;  while  Einhorn  suggests 
reflex  irritation  of  the  vagus  fibers.  In  view  of  the  fact  that  the  jnajority 
of  cases  occur  after  dietetic  error,  Riegel's  suggestion  of  auto-intoxication 
as  a  factor  seems  to  have  a  decided  hearing  on  the  subject. 

On  the  other  hand,  under  Acute  Dilatation  of  the  Stomach  I  referred 
to  certain  peculiar  clinical  types,  in  one  of  which  many  of  the  symptoms 
resembled  angina  pectoris,  there  being  dyspnea  and  rapid  and  feeble 
heart  action,  and  in  some  attacks  loss  of  consciousness.  These  attacks 
followed  indiscretion  in  diet.  In  view  of  this  fact  and  also  that  Henoch 
describes  distention  of  the  stomach  as  present  in  most  cases,  and  dietary 
indiscretion  as  a  cause,  it  would  seem  to  me  that  in  this  type  at  least  acute 
gastric  dilatation  from  auto-intoxication  is  a  factor.  Einhorn  describes 
acute  cases  following  excesses  in  eating,  drinking  or  smoking,  excitement, 
or  from  no  discoverable  cause.  Even  these  facts  do  not  mitigate  against 
the  theory  of  distention. 

The  second  group  which  he  classifies  are  more  of  a  chronic  type,  appear- 
ing after  meals,  or  after  overexertion,  or  without  apparent  cause,  or  those 
appearing  several  hours  after  meals  spontaneously,  or  after  exertion. 

In  some  of  these  cases  a  small  amount  of  food  would  check  the  attack. 
The  last  type  would  seem  to  suggest  reflex  irritation  from  hyperchlor- 
hydria,  for  example,  which  when  relieved  would  stop  the  asthma. 

1  Berlin,  klin.  Wochens.,  1876,  No.  181. 

2  Ibid.,  1882,  No.  23. 

^  AUgem.  Med.  Central.  Zeit.,  1890,  No.  71,  p.  849. 

*  Arch.  f.  Verdauungskrank.,  Bd.  11,  1896,  p.  444. 

*  N.  Y.  Med.  Jour.,  Jan.  12,  1901. 

*  Jour.  .\mer.  Med.  Assoc,  Feb.  i,  1902. 

499 


500  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Some  of  the  last  group  present,  in  some  cases,  symptoms  suggestive 
of  pseudo-angina  pectoris. 

Secretory  Functions. — Achylia  gastrica  has  been  found  in  some  patients 
and  hyperchlorhydria  in  others.  Treatment  of  these  conditions  caused 
subsequent  disappearance  of  the  attacks  of  asthma.  With  achylia  the 
coarse  particles  of  food,  Einhorn  believes,  might  cause  reflex  irritation  of 
the  vagus.     Asthma  dyspepticum  may  also  occur  with  chronic  gastritis. 

On  the  other  hand,  these  attacks  have  occurred  in  patients  in  whom 
the  gastric  secretion  was  normal;  and  Boas  believes  that  h)^eresthesia 
of  the  stomach  with  reflex  irritation  is  the  cause. 

Again,  in  my  case  of  acute  dilatation  with  some  of  the  attacks  similar 
to  angina,  the  gastric  secretion  was  normal;  but  dietary  indiscretion  pro- 
duced gastric  distention  and  the  attack  noted.  It  was  immediately 
relieved  by  vomiting. 

Floating  liver  was  noted  by  Einhorn  in  five  cases,  and  this  together  with 
abdominal  ptosis  of  other  organs;  and  he  believes  that  the  prolapsed  liver, 
by  dragging  down  the  diaphragm,  may  be  a  cause  of  this  type  of  asthma. 
In  my  own  opinion,  ptoses  of  the  viscera  have  an  influence  on  the  secretory 
conditions  in  the  gastro-intestinal  tract,  and  only  to  this  degree  predispose 
to  dyspeptic  asthma.  Probably  these  various  factors  to  which  I  have 
referred  may  have  a  bearing  in  different  cases. 

Treatment. — Disorders  of  the  gastric  secretion  must  be  appropriately 
corrected,  and  ptosis  of  the  viscera  supported  by  Rose's  adhesive  belt. 

Excesses  in  the  use  of  alcohol  and  tobacco  must  be  corrected,  mental 
worry  and  strain  be  avoided,  and  the  mode  of  life  must  be  regulated. 

All  indigestible  food  must  be  avoided  and  diet  suitable  to  each  case 
must  be  instituted.  By  this  means  many  cases  will  be  relieved  and  often 
cured. 

In  acute  cases  with  distention  of  the  stomach,  lavage  is  indicated, 
also  calomel,  5  grains  (0.3),  followed  by  a  saline  cathartic.  Catharsis  is 
also  indicated  in  cases  following  excesses  in  eating  or  drinking. 


CHAPTER  XIX 
THE  STOMACH  FUNCTIONS  IN  DISEASES  OF  OTHER  ORGANS 

Unquestionably  there  are  few  diseases,  either  constitutional  or  local, 
which  are  not  attended  to  a  greater  or  lesser  degree  by  some  disturbance 
of  the  digestive  organs.  These  are  dependent  on  the  general  disturbance 
of  the  organism  and  are  appropriately  discussed  under  the  symptoms  of 
each  disease. 

In  the  present  chapter  I  shall  only  briefly  refer  to  those  diseases  in 
which  disturbances  of  the  gastric  functions  are  particularly  conspicuous. 

FUNCTIONS  OF  THE  STOMACH  IN  ACUTE  FEBRILE  DISEASES 

Numerous  investigations  have  been  carried  out  both  on  animals  and 
men,  in  some  of  which  at  least  accurate  quantitative  gastric  analyses  were 
performed.  Riegel  concludes  that  we  are  probably  justified  in  stating 
that  in  acute  febrile  infectious  diseases  the  production  of  hydrochloric 
acid  was  more  frequently  reduced  than  normal,  and  the  secretion  of  pepsin 
is,  as  a  rule,  unchanged.  Probably  the  fever  is  responsible  and  the  condi- 
tion is  temporary.  Von  Noorden^  showed  that  hydrochloric  acid  reaction 
can  be  obtained  in  fever  cases  if  pepper  and  salt  are  administered  with  the 
food. 

Some  interesting  researches  have  been  carried  out  in  numerous  cases 
of  typhoid  and  pneumonia.  During  the  high  temperature  of  these  dis- 
eases there  was  a  marked  diminution,  and  in  some  cases  an  absence  of 
hydrochloric  acid.  During  defervescence  an  increase  of  the  secretion  was 
noted.  During  high  temperatures  pure  milk  was  found  in  the  stomach  in 
a  curdled  condition  several  hours  after  the  normal  time  for  evacuation, 
and  in  one  case,  on  autopsy,  the  stomach  was  found  filled  with  the  curdled 
milk  of  previous  feedings,  thus  demonstrating  a  diminution  of  the  motor 
function.  Water  alone  was  then  administered  at  this  period.  During 
lower  temperatures  the  administration  of  foods  freely  soluble  in  water,  such 
as  broths  and  gruels,  were  found  to  be  best.  There  were  less  fermentation 
and  distention  under  this  method  of  feeding  and  the  stomach  more  readily 
emptied  itself. 

In  my  own  experience^  I  can  confirm  the  fact  that  during  the  high 
temperature  of  typhoid  the  free  hydrochloric  acid  diminished,  often  mark- 
edly, and  the  motor  function  is  not  as  active.  It  has  also  been  found  that 
biliary  secretion  is  disturbed  during  high  fever.  Stolmkow  noted  dis- 
turbances in  the  pancreatic  secretion  during  high  temperature.  These 
facts  demonstrate  that  the  excessively  high  calorie  food  values  advocated 
by  some  in  typhoid  fever  are  unscientific. 

^Lehrbuch  der  Pathologic  des  Stoffwechsels,  1893. 
-  Amer.  Med.,  May,  1909. 

501 


502  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

CHRONIC  FEBRILE  CONDITIONS 

Observers  vary  considerably  in  their  findings  in  the  gastric  secretion 
in  these  cases,  some  noting  no  changes  whatever.  In  my  own  experience 
the  temperature,  as  a  rule,  caused  disturbance  in  the  secretory  function 
of  the  stomach,  lessening  the  HCl  production.  The  type  of  disease,  the 
physical  condition,  the  personal  equation  of  the  patient,  and,  most  im- 
portant, the  time  at  which  the  analysis  is  made,  all  have  a  hearing.  I  shall 
refer  to  the  work  of  Hildebrandt  on  this  subject,  under  Tuberculosis.  The 
power  of  absorption  seems  to  be  impaired  in  fever  (Sticker).^ 

CONDITION  OF  THE  STOMACH  IN  PULMONARY  TUBERCULOSIS 

Phthisis  quite  frequently  begins  with  dietetic  disturbances,  such  as 
heart-burn,  belching,  pressure,  nausea,  loss  of  appetite,  constipation  alter- 
nating with  diarrhea,  and  even  vomiting,  with  the  lung  symptoms  so 
slight  as  to  be  at  first  overlooked.  It  has  been  called  pretubercular  dys- 
pepsia. In  the  later  stages  we  may  have  the  dyspeptic  symptoms  quite 
marked. 

Hildebrandt^  found  the  following  results:  The  cases  in  which  free 
hydrochloric  acid  was  present  usually  had  no  fever,  while  those  in  whom  it 
was  absent  suffered  from  continuous  fever.  When  it  was  absent  at  one 
part  of  the  day,  it  was  when  the  temperature  was  high;  and  when  present 
at  another  part,  it  was  when  the  temperature  was  low.  The  temperature, 
therefore,  exercised  an  influence.  These  findings  were  in  advanced  cases. 
Klemperer^  studied  lo  cases  in  the  initial  stage,  three  in  the  advanced, 
and  one  in  the  moderate. 

In  the  beginning  the  secretory  power  of  the  stomach  was  usually  in- 
creased, often  normal,  and  rarely  reduced.  In  the  terminal  stages,  always 
greatly  reduced.  Motor  reduction  slight  in  the  initial  stages,  reduced  in 
later  stages. 

Brieger*  analyzed  64  cases:  31  advanced,  with  continuous  fever;  37 
moderate,  with  more  or  less  fever;  6  incipient  cases,  with  no  fever.  Gas- 
tric secretion  normal  in  16  per  cent,  of  advanced  cases,  and  in  the  others 
insufficiency  of  varying  degrees;  in  9.6  per  cent,  absence  of  free  hydrochloric 
acid.  In  moderate  cases,  ^T^^i  per  cent,  normal,  and  in  all  others  perver- 
sion; and  in  6.6  per  cent,  normal  secretion  absent.  In  the  initial  cases, 
normal  secretion  and  perversion  were  equally  divided. 

Einhorn''  has  shown  in  analyses  of  15  cases  that  the  appetite  does  not 
seem  to  correspond,  as  would  be  expected,  to  the  gastric  findings;  and 
also  that  frequently  the  subjective  symptoms  do  not  harmonize  with  the 
objective  findings. 

Treatment.^-The  main  indication  is  to  improve  the  resisting  power 
of  the  patient  against  the  primary  disease. 

Forced  feeding,  especially  by  Russell's  method,  rest  in  bed,  and  fresh 

1  Deutsch.  raed.  Wochens.,  1889,  No.  15. 

*  Berlin,  klin.  Wochens.,  1885. 
»  Ibid.,  1889,  No.  2. 

*  Deutsch.  med.  Wochens.,  1889,  No.  14. 

*  Loc.  cit. 


STOMACH    FUNCTIONS   IN   DISEASES    OF    OTHER   ORGANS  503 

air,  with  milk  and  vegetable  juices,  I  believe  the  best  treatment  for  the 
tuberculosis  when  the  patient  is  unable  or  not  compelled  to  work.  I  have 
seen  a  gain  of  15  to  25  pounds  in  each  case  by  his  methods  at  Ward's 
Island  in  12  cases  in  eight  weeks. 

The  heart  and  kidneys  must  functionate  properly  for  success  with 
his  method.  I  have  also  employed  a  diet  such  as  I  use  in  gastroptosis  to 
improve  the  nutrition,  though  the  presence  of  temperature  would  modify 
the  power  of  assimilation.  I  know  of  some  excellent  results  in  the  treat- 
ment by  RusselF  of  his  ambulant  cases  with  a  diet  based  upon  his  theory 
of  "lime  starvation,"  though  I  can  express  no  opinion  as  to  the  correct- 
ness of  his  view.  Functional  disturbances  of  the  stomach  should  be  treated. 
Tuberculous  ulcer  of  the  stomach  is  occasionally  met  with  in  connection 
with  tuberculosis  of  the  other  organs;  the  primary  condition  is  rare. 

PELLAGRA 

The  changes  in  the  gastro-intestinal  vary  in  degree,  being  most  marked 
in  the  acute  forms. 

In  the  acute  form  (typhus  pellagrosus)  there  is  a  chronic  gastro- 
enteritis with  the  formation  of  ulcers  and  swelling  of  the  mesenteric  glands. 
In  acute  cases  true  gastritis  has  been  found  and  atrophy  of  the  muscular 
coat  of  the  stomach  (achylia)  has  been  noted.  The  gastro-intestinal 
symptoms'  are  the  earliest,  most  persistent  and  dangerous;  they  may 
begin  with  sore  mouth,  nausea,  gastralgia  (pyrosis),  distention  and 
belching. 

CHLOROSIS  AND  ANEMIA 

Among  the  gastric  symptoms  in  these  conditions  are  found  gastralgia, 
anorexia,  hyperesthesia  of  the  stomach,  hyperchlorhydria,  and  chronic 
atony. 

These  symptoms  appear  more  frequently  after  eating,  than  on  an  empty 
stoMiach,  and  occur,  as  a  rule,  in  attacks  at  irregular  intervals.  There  are 
often  perversions  of  appetite.  The  atony,  if  neglected,  may  progress  to 
chronic  atonic  ectasia. 

In  chlorosis  (primary  anemia)  the  hydrochloric  acid  secretion  is,  as  a 
rule,  increased. 

In  anemia  (secondary),  on  the  other  hand,  depending  on  the  causative 
disease  we  may  find  variable  results;  hydrochloric  acid  decreased,  normal, 
or  (more  rarely)  increased. 

The  relation  between  achylia  gastrica  and  pernicious  anemia  has 
already  been  described.  The  relation  of  intestinal  putrefaction  to  this 
disease  is  described  later. 

Many  of  the  derangements  belong  to  the  neuroses  and  are  dependent 
on  the  condition  of  the  blood.  The  administration  of  iron  is  chiefly  indi- 
cated, with  the  additional  correction  of  the  functional  disturbance,  if  such 
be  present. 

^  Medical  Record,  June  17,  1916. 

*  Medical  Record,  March  22,  1913. 

*  Roberts,  Pellagra,  p.  107. 


504  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

HEART  LESIONS 

In  general  we  may  say  that  while  compensation  is  present,  in  many 
cases  the  stomach  functions  are  normal  or  nearly  so;  with  imperfect  or 
failing  compensation,  with  resulting  stasis  and  hyperemia  in  the  gastric 
mucous  membrane,  I  have  noted  diminution  in  the  amount  of  free  hydro- 
chloric acid  with  accompanying  digestive  disturbances,  belching,  epi- 
gastric distention  with  a  feeling  of  pressure,  anorexia,  and  at  times  nausea 
and  even  vomiting,  with  sick  headache.  These  conditions  improved  after 
treatment  was  directed  to  the  circulation.  In  severe  cases  free  HCl  may  be 
absent.  In  one  case  with  poor  compensation  and  frequent  gastric  attacks, 
a  course  of  treatment  at  Nauheim  produced  excellent  results. 

Symptoms  simulating  heart  lesions  may  be  produced  by  gastric  dis- 
orders, thus:  Ulcer,  chronic  ectasy,  and  chronic  gastritis  may  produce 
bradycardia  or  arrhythmia;  or  tachycardia  may  occur  with  chronic 
gastritis,  in  nervous  gastric  disorders,  or  with  atony. 

Tachycardia  with  acute  dilatation  of  the  stomach,  especially  with 
existing  heart  lesions,  the  author  has  described  in  the  chapter  on  Acute 
Ectasy. 

DISEASES  OF  THE  LIVER 

Diseases  of  the  liver  are  generally  accompanied  by  gastric  symptoms; 
with  cirrhosis  and  the  resulting  circulatory  disturbances  of  the  viscera,  the 
gastric  secretion  (free  hydrochloric  acid)  is  more  frequently  diminished. 
The  findings  in  other  liver  disturbances  are  not  constant.  Hematemesis 
may  occur  with  cirrhosis,  acute  yellow  atrophy,  etc. 

ANEURYSM 

In  a  case  of  aneurysm  of  the  celiac  axis,  referred  to  under  Cancer,  free 
hydrochloric  acid  was  absent,  lacid  acid  present,  and  the  stomach  dilated. 
Circulatory  disturbances  were  responsible  for  the  gastric  findings  and 
pressure,  for  the  dilatation  of  the  stomach. 

DISEASES  OF  THE  KIDNEYS 

Gastric  disturbances  are  frequent  in  nephritis,  and  nausea  and  vomit- 
ing may  be  the  first  symptoms.  In  fact.  Osier  has  reported  death  with 
these  symptoms,  and  nephritis  may  be  unsuspected  until  autopsy.  The 
excretion  of  urea  through  the  gastric  mucous  membrane,  or  cerebral  irrita- 
tion from  the  poison  are  responsible  for  the  vomiting.  Variable  conditions 
of  the  gastric  secretion  have  been  reported  by  various  observers. 

Biernaki^  has  studied  25  cases  of  nephritis,  both  acute  and  interstitial, 
and  found  in  general,  the  gastric  secretion  was  diminished,  and  also  that 
the  quantity  of  free  hydrochloric  acid  was  reduced  in  proportion  to  the 
extent  of  the  edema,  the  excretion  of  albumin,  and  the  reduction  in  the 
quantity  of  urine  excreted.  Pepsin  was  reduced  and  the  motor  function 
was  increased.  Free  hydrochloric  acid  was  present  in  the  mild  cases  in 
large  or  small  quantities. 

1  Berlin,  klin.  Wochens.,  1891,  Nos.  25  and  26. 


STOMACH   FUNCTIONS    IN    DISEASES    OF    OTHER    ORGANS  505 

Einhorn  has  observed  achylia  gastrica  in  a  case  of  renal  calculus,  which 
disappeared  after  operation,  and  A.  A.  Jones*  has  found  achylia  gastrica 
among  patients  with  kidney  distutbances. 

DIABETES 

The  digestion  is  sometimes  good  in  diabetic  patients,  so  that  frequently 
the  functions  of  the  stomach  are  never  examined. 

Variable  results,  however,  have  been  secured.  Atrophy  of  the  gastric 
mucosa  has  been  found  in  a  few  cases.  The  motor  power  was  good.  The 
gastric  motility  is  quite  frequently  markedly  increased,  so  that  it  may  be 
necessary  to  aspirate  a  test-breakfast  within  less  than  half  an  hour  after 
its  ingestion. 

Rosenstein^  reports  normal  secretion  in  four  cases  and  abnormal  in  six, 
while  Gans^  found  six  normal  and  four  negative.  Gilbride'*  finds  that  the 
secretion  of  pepsin  is  frequently  reduced  and  sometimes  absent;  also  that  a 
high  percentage  of  hydrochloric  acid  does  not  indicate  a  good  pepsin  digestion. 
Hydrochloric  acid  was  absent  in  three  of  the  seven  cases  reported.  Chronic 
gastritis  has  been  associated  in  some  cases.  The  findings  are  not  constant, 
and  both  normal  and  abnormal  conditions  of  the  secretion  have  been 
observed.  Hydrochloric  acid  may  be  absent  for  a  long  time  and  then 
reappear.  As  most  diabetics  have  arteriosclerosis,  it  is  probable  that  the 
latter  accounts  for  some  of  the  changes  in  gastric  functions  in  certain  cases. 

ARTHRITIS  DEFORMANS 

In  one  easel  found  hyperchlorhydria  marked;  and  Einhorn  reports 
one  case  of  achylia.  The  relation  of  intestinal  putrefaction  to  arthritis 
deformans  is  described  later  under  that  topic. 

GOUT 

In  two  cases  Einhorn  reports  achylia,  and  in  several  mild  cases 
hyperchlorhydria. 

Grip. — Gastric  disturbances  are  reported  by  Kaufmann  in  grip. 

MALARIA 

Gastralgia  may  occur  as  a  substitute  for  the  malarial  paroxysms  and 
has  already  been  described,  or  vomiting  may  be  present,  associated  with 
malarial  symptoms.  There  are  no  characteristic  features  of  the  gastric 
secretion,  but  in  the  latter  cases  free  hydrochloric  acid  may  be  diminished. 

Arteriosclerosis. — General  arteriosclerosis  may  affect  the  gastric  vessels 
and  produce  disturbances.  Harlow  Brooks  refers  to  arteriosclerosis  oc- 
curring chiefly  in  the  abdominal  vessels.  The  possibility  of  this  latter 
condition  should  be  considered  (see  Visceral  Arteriosclerosis). 

'  N.  Y.  Med.  Jour.,  Jan.  19,  1895. 

"  Berlin,  klin.  Wochens.,  1890,  No.  15. 

'  IX  Congress  f.  innere  Medicin,  1890,  Wiesbaden. 

*Jour.  Amer.  Med.  Assoc.,  Feb.  18,  191 1. 


5o6  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

DISEASES  OF  THE  EYE 

Reflex  disturbances  of  the  stomach,  loss  of  appetite,  irritability  such 
as  nausea  and  vomiting,  dizziness  and  dyspeptic  symptoms  regardless 
of  the  nature  of  the  food  may  result  from  eye  strain.  Headache  may  be 
present.  Eye  strain  due  to  errors  of  refraction,  disturbances  of  accom- 
modation or  of  motility,  iritis  or  glaucoma  are  examples  of  factors  pro- 
ducing reflex  gastric  disturbances. 

DISEASES  OF  THE  EAR,  NOSE  AND  THROAT 

Acute  conditions  of  these  organs  are  responsible  for  gastric  disturbances, 
while  chronic  discharge  will  also  directly  affect  the  stomach.  These 
facts  simply  emphasize  the  necessity  of  a  complete  physical  examination. 

DISEASES  OF  THE  SKIN 

Eczema. — Various  systemic  conditions  probably  have  a  bearing,  and 
in  some  few  cases  correction  of  the  digestive  disturbances  seem  to  have  an 
influence  in  improving  the  condition.  In  one  case  I  found  hyperchlor- 
hydria,  and  in  another  deficient  hydrochloric  acid. 

Hyde^  believes  that  gout,  dyspepsia,  constipation,  and  scrofula  have 
a  decided  influence. 

James  C.  Johnston^  reports  on  the  toxic  effects  in  the  skin  resulting 
from  disorders  of  digestion  and  metabolism.  He  finds  hyperchlorhydria 
most  frequent,  and  intestinal  fermentation  with  constipation  and  indi- 
canuria  as  accompaniments.  Among  the  cases  cited  are  loss  of  hair  in 
acneif  orm  dermatitis  with  hyperacidity  and  gastro-intestinal  crises.  There 
were  subsequent  attacks  of  colitis.  In  some  of  the  attacks  no  errors  of 
diet  were  apparent  and  Johnston  believes  them  to  be  anaphylactic  through 
protein  absorption.  With  urticaria,  eczema,  dermatitis  herpetiformis, 
prurigo,  psoriasiform  scaling  of  scalp,  purpura,  pompholyx,  scaling  derma- 
tosis, and  herpes  facialis  change  occurred  in  nitrogen  partition.  There 
were  most  often  a  decrease  of  urea  and  a  corresponding  increase  in  the 
rest  nitrogen  fractions.  Detoxicated  thyroid  to  promote  urea  synthesis, 
hydrotherapy  and  reduction  of  nitrogen  intake  were  valuable  accessories 
in  the  treatment.  Such  susceptibility  may  be  an  hereditary  transmission. 
Johnston  reports  cases  of  angioneurotic  edema,  chronic  urticaria  and  ulcera- 
tive stomatitis  presenting  the  aspects  of  anaphylaxis,  one  showing  an 
inherited  tendency,  but  the  urticaria  case,  the  appearance  of  resulting 
anaphylaxis  from  absorption  of  certain  definite  proteins  from  the  digestive 
tract.  Adrenalin  and  atropin  proved  of  value  in  urticaria  as  in  the 
anaphylaxis  of  animals. 

Acne  Simplex  and  Acne  Rosacea. — These  are  associated  at  times  with 
gastric  disturbances.  Einhorn  reports  two  cases  of  acne  rosacea  in  whom 
chronic  continuous  gastrosuccorrhea  was  found.  The  correction  of  the 
latter  benefited  the  skin  affection. 

^  Twentieth  Century  Practice,  vol.  v. 

*  Journal  of  Cutaneous  Diseases,  Including  Syphilis,  March,  1912. 


STOMACH    FUNCTIONS    IN    DISEASES    OF    OTHER    ORGANS  507 

Psoriasis. — The  treatment  of  gastric  disorders  in  this  afifection  does 
not  seem  to  benefit  the  lesion,  according  to  Einhorn. 

Urticaria  and  Eryihema.. — Some  persons  have  an  idiosyncrasy  to  lob- 
sters, crabs,  strawberries,  etc.,  and  develop  therefrom  poisonous  substances 
which  produce  these  eruptions,  associated  at  times  with  acute  gastric 
symptoms.  These  conditions  were  formerly  considered  due  to  auto- 
intoxication. Combe  ("  Intestinal  Auto-intoxication  ")  believes  that  acne, 
the  seborrheic  eczemas,  urticaria,  pruritus,  strophulus  infantum,  and 
furunculosis  to  be  chiefly  due  to  intestinal  auto-intoxication.  He  advises 
fresh  brewer's  yeast,  i  dram  (4.0)  t.i.d.  before  meals,  for  these  conditions. 
Duncan  Bulkley  holds  that  cutaneous  lesions  are  in  some  cases  produced 
through  cutaneous  elimination  of  toxic  substances.  As  noted  above  these 
conditions  are  held  by  others  to  be  the  result  of  protein  absorption  with 
anaphylaxis.  This  explanation  is  reasonable  though  intestinal  toxemia 
might  play  a  part  in  some  cases.  Protein  absorption  would  not  explain 
the  case  of  strawberries  in  the  author's  opinion.  The  author  holds  that 
the  entire  gastrq-intestinal  tract  should  receive  attention.  Thorough 
catharsis  should  be  carried  out.  These  foods  should  thereafter  be 
avoided. 

Pemphigus  of  the  Mouth. — Einhorn  has  noted  three  cases  in  which 
there  was  hyperchlorhydria  or  neurasthenia  gastrica,  and  in  two  cases 
improvement  resulted  from  treating  the  gastric  symptoms. 

In  general,  we  may  say  that  considerable  investigation  is  still  neces- 
sary to  definitely  determine  the  relations  of  gastric  disturbances  to  skin 
diseases. 

TUBERCULOSIS  OF  THE  STOMACH 

History. — Tuberculosis  of  the  stomach  is  a  comparatively  rare  condi- 
tion. Arloing  in  1903  collected  147  cases  and  Ricard  and  Chevrier  in 
1905  discussed  107  cases.  Winternitz  in  1908,  refers  to  seven  cases  of 
primary  and  47  cases  of  secondary  tuberculosis  of  the  stomach  reported  up 
to  1 901,  and  nine  or  more  secondary  cases  since  that  date.  From  these 
diverse  statements,  it  seems  difficult  to  decide  on  the  authenticity  of  some 
of  the  reported  cases.  A.  G.  Ellis,  in  the  New  York  Medical  Journal, 
March  12,  1910,  reports  two  cases.  In  the  first  patient,  the  condition  was 
secondary  to  an  extensive  pulmonary  tuberculosis.  There  were  numerous 
gastric  ulcers  and  a  number  of  tubercles  in  the  gastric  mucosa.  In  the 
second  patient,  there  were  several  ulcers,  a  number  of  tubercles,  and  a 
cyst  containing  tubercle  bacilli.  There  was  a  chronic  tuberculous  peritoni- 
tis with  adhesions.  These  cases  were  found  at  autopsy;  as  are  most  cases 
of  tuberculous  gastric  ulcer.  Tuberculous  ulcers  of  the  pylorus,  with  nar- 
rowing of  the  orifice,  have  been  reported,  and  Ricard  and  Chevrier  de- 
scribe a  sclerosing  type  of  pyloric  tuberculosis. 

Anatomic  Types  of  Gastric  Tuberculosis. — There  may  be  a  single 
ulcer  or  multiple  ulcers.  Diffuse  miliary  tuberculosis  of  the  organ  may 
be  present  and  more  rarely  solitary  tubercles.  Tumor-like  masses,  usually 
at  the  pylorus,  have  been  described.  They  may  simulate  carcinoma. 
Tuberculous  cicatricial  pyloric  stenosis  may  occur. 


5o8  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

Diagnosis. — The  determination  of  pulmonary  tuberculosis,  or  a  tuber- 
cular focus  elsewhere  is  of  value,  as  gastric  tuberculosis  is  most  frequently 
a  secondary  condition.  Syphilis  must  be  excluded  by  the  Wassermann 
and  Noguchi  tests.  A  persistent  afternoon  elevation  of  temperature  is 
suggestive.     The  tuberculin  test  should  be  made  for  diagnostic  purposes. 

Symptoms. — There  are  no  specific  symptoms  of  gastric  tuberculosis. 
The  tubercular  ulcer  is  chronic,  is  not  as  apt  to  bleed  as  the  simple  ulcer, 
and  the  pain  is  liable  to  be  severe  in  character. 

Treatment. — ^Pulmonary  tuberculosis  or  any  other  tubercular  primary 
lesion  should  receive  appropriate  treatment.  Carbonate  of  creosote  or 
guaiacol  carbonate,  5  grains  (0.3)  three  or  four  times  a  day,  are  indicated 
for  tubercular  gastric  ulcer;  thiocol,  10  grains  (0.6)  t.i.d.  is  excellent. 
Also  the  bismuth  preparations  and  proper  feeding.  Iron,  arsenic,  and  the 
fats  should  be  employed.  Tuberculin  may  be  employed  cautiously  by 
injection. 

Surgery. — If  a  localized  tubercular  process,  ulcer,  or  tubercular  mass 
can  be  diagnosed,  excision  is  indicated. 

SYPHILIS  OF  THE  STOMACH 

Gastric  symptoms  quite  frequently  occur  in  the  secondary  and  tertiary 
stages  of  syphilis.  In  the  secondary  stage  they  may  often  be  attributed 
to  fever  (the  constitutional  condition)  though  at  times  a  gastric  syphilitic 
lesion  may  be  responsible;  while  in  the  tertiary  stage  there  are  anatomic 
changes  in  the  stomach  itself. 

Fen  wick  ^  believes  that  syphilis  may  affect  the  stomach  in  three  ways: 
By  the  formation  of  gummata,  by  producing  endarteritis,  and  by  a  chronic 
inflammation  of  the  mucous  membrane.  The  symptoms  arising  subside 
under  antisyphilitic  treatment. 

Flexner^  holds  that  syphilitic  gastric  ulcer  is  not  rare,  while  Dieulafoy^ 
notes  various  lesions,  such  as  hemorrhagic  erosions,  ecchymoses,  gummata, 
infiltration  of  the  submucosa  and  circumscribed  gummatous  ulceration, 
and  cicatrices  of  the  latter.  Hour-glass*  stomach  may  result.  Pain, 
emaciation,  vomiting,  hematemesis,  and  melena  occur  in  some  cases. 

RiegeP  reports  12  cases  in  which  they  complained  of  gas,  nausea,  dis- 
tress after  eating,  and  gastralgia,  which  responded  promptly  to  antisyphi- 
litic remedies. 

Death  has  resulted  from  perforation  of  a  broken-down  gumma. 

All  doubtful  cases  should  be  examined  for  signs  of  previous  S3rphilitic 
infection,  for  active  syphilitic  manifestation  and  also  as  to  the  history. 
Wassermann 's  or  Noguchi's  test  should  be  made.  If  this  is  not  feasible 
then  the  diagnosis  must  be  made  by  the  usual  methods  of  physical  ex- 
amination for  sjrphilis  and  should  be  tested  by  specific  treatment.  Of 
course,  many  patients  may  have  digestive  disturbances  without  any  con- 
nection with  the  old  luetic  condition. 

1  London  Lancet,  Sept.  20,  1901. 

2  Amer.  Jour.  Med.  Sci.,  Oct.,  1898. 
'  Gaz.  Heb.  de  Med.,  1902. 

*  Cronin,  Interstate  Med.  Jour.,  Sept.,  1914. 
'  Diseases  of  the  Stomach. 


STOMACH    FUNCTIONS    IN    DISEASES    OF    OTHER   ORGANS  509 

Hemmeter^  has  described  syphilis  of  the  stomach. 

Einhorn^  gives  the  following  classification  and  describes  cases: 

(i)  Gastric  ulcer  of  syphilitic  origin. 

(2)  Syphilitic  tumor  of  the  stomach. 

(3)  Syphilitic  stenosis  of  the  pylorus. 
To  this  I  shall  add  2i  fourth  type: 

(4)  Syphilitic  cirrhosis  of  the  stomach. 
Smithies  describes  in  addition:' 

(5)  Chronic  gastritis. 

(6)  Perigastritis. 

His  article  on  "Syphilis  of  the  Stomach"  is  well  worth  studying.  He 
reports  26  cases. 

(i)  Gastric  Ulcer  (Syphilitic) 

A  number  of  cases  have  been  reported  in  which  the  usual  treatment  for 
ulcer  failed,  and  which  made  complete  recovery  under  specific  treatment. 

(2)  Syphilitic  Tumor  of  the  Stomach 

This  condition  is  excessively  rare.  Einhorn  has  reported  two  cases,  and 
refers  to  the  fact  that  they  may  run  their  course  like  carcinoma.  I  re- 
ferred to  a  case  in  this  volume  under  Differential  Diagnosis  in  Carcinoma 
of  the  Stomach.  In  this  patient  the  gastric  analysis  showed  absence  of 
hydrochloric  acid  and  lactic  acid  abundant.  The  patient  had  lost  77 
pounds  in  eight  months  and  was  vomiting  continuously.  The  stomach 
was  dilated  to  below  the  umbUicus,  and  though  he  had  been  on  specific 
treatment  for  a  time  before  I  saw  him,  the  pyloric' obstruction  was  so 
marked  that  drainage  of  the  stomach  was  necessary  to  preserve  life. 
Palpation  gave  a  sense  of  resistance  at  pylorus. 

A  rapid  laparotomy  at  the  Red  Cross  Hospital  disclosed  a  gummatous 
tumor  at  the  posterior  wall  of  the  pylorus,  nearly  blocking  it.  Gastro- 
enterostomy was  performed  and  specific  treatment  pushed.  There  was 
no  more  vomiting  and  the  case  steadily  improved.  Niles^  also  recently 
reports  a  case  of  gastric  syphilis  with  findings  suggestive  of  carcinoma. 

(3)  Syphilitic  Pyloric  Stenosis 

Einhorn  reports  a  case  of  pyloric  stenosis  cured  by  antis5T)hilitic  treat- 
ment. In  most  of  these  cases,  however,  gastro-enterostomy  is  required 
in  addition  to  the  antiluetic  treatment.  The  following  case  of  syphilis  with 
gastric  ulcer  and  pyloric  stenosis  is  instructive.  Infection  dated  posi- 
tively from  June,  1915.  Wassermann  4-f-,  on  August  i,  1915.  Patient, 
male,  aged  thirty-six.  Gastric  disturbances  for  several  months  previous 
to  my  first  examination  which  was  April  15,  1916.  A  month  previous  to 
this,  early  in  March,  1916,  patient  began  to  have  attacks  of  severe  pain  in 
the  stomach,  crampy  in  character,  and  vomiting  spells,  which  afforded 

1  Diseases  of  the  Stomach,  p.  556,  1897. 
*  Ibid.,  p.  534,  1906. 

'Smithies,  Journal  A.  M.  A.,  Aug.  14,  1915. 
♦Niles,  Ibid.,  Feb.  19,  1916. 


5IO  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

relief.  A  specialist  in  venereal  disease  had  injected  salvarsan  three  times 
and  in  addition  22  mercurial  injections  from  early  August,  191 5,  to  early 
March,  191 6.  At  this  last,  when  vomiting  first  started  all  specific  treat- 
ment was  stopped,  gastric  disturbance  being  imputed  to  the  mercury.  No 
examination  of  the  stomach  was  made.  The  patient  grew  steadily  worse. 
The  specialist  certainly  made  a  fatal  error  in  stopping  treatment.  By 
the  middle  of  April  patient  had  lost  12  pounds  in  weight  and  had  cramp 
attacks  with  vomiting  several  times  daily — often  of  material  taken  hours 
before.  The  prepuce  was  swollen,  slight  eruption  about  head  of  penis, 
inguinal  glands  enlarged.  After  the  test  breakfast,  the  stomach  (lower 
border)  apparently  slightly  distended,  to^  about  reach  the  upper  edge  of 
the  umbilicus.  It  was  interesting  to  note,  however,  that  though  the  radio- 
graph showed  marked  retention  at  the  end  of  six  hours;  the  stomach  was  not 
apparently  dilated.  The  fibrous  formation  and  blocking  of  the  pylorus, 
•therefore,  must  have  been  extremely  rapid,  after  cessation  of  the  specific 
treatment;  aspiration  one  hour  after  Ewald's  test  breakfast  yielded  a 
residuum  of  350  c.c.  and  H  glass  of  spinach  ingested  fourteen  hours  before. 

The  gastric  findings  were  of  benign  stenosis — total  acidity  85+;  free 
HCl  55+;  comb.  HCl  25  + ;  acid  salts  5+;  no  occult  blood — no  occult 
blood  in  the  stool.  Fig.  239  is  the  radiograph  of  the  six-hour  retention. 
On  account  of  the  rapidly  developed  symptoms  and  marked  stenosis,  I 
advised  immediate  gastro-enterostomy  in  addition  to  mercurial  injec- 
tions. The  surgeon,  Wm.  P.  Healy,  to  whom  I  referred  him,  concurred 
in  this  view.  The  patient  at  first  refused  operation — mercurial  injections 
were  pushed — appropriate  treatment  for  the  hyperacidity — belladonna 
and  alkalis,  olive  oil,  forced  liquid  feeding,  raw  eggs,  cream,  butter,  etc.; 
the  Rose  belt  applied  and  the  patient  directed  to  lie  on  the  right  side  after 
each  feeding.  He  insisted  continuing  at  business  so  that  lavage,  which 
should  have  been  consistently  followed,  could  not  be  carried  out.  The 
first  week,  in  spite  of  the  omission,  he  gained  4  pounds  and  was  delighted. 
I  still  advised  operation.  The  next  ten  days  he  lost  8  pounds  and  was 
then  immediately  operated  on  by  Dr.  McGrath — in  Dr.  Healy's  absence. 
The  result  of  the  gastro-enterostomy  has  been  a  gain  in  weight  of  1 5  pounds 
in  three  weeks  and  disappearance  of  all  symptoms.  Mercury,  of  course, 
should  be  continued  persistently  and  also  further  salvarsan  or  neo- 
salvarsan  injection. 

It  is  interesting  to  note  that  this  patient  undoubtedly  acquired  his 
stenosis  from  a  syphilitic  ulcer,  during  the  second  stage  of  syphilis,  and  the 
gastric  findings  were  of  benign  stenosis.  On  the  other  hand,  my  case  of 
pyloric  stenosis  (syphilitic),  due  to  gumma,  showed  findings  much  like 
gastric  cancer;  which  would  be  expected  from  the  tertiary  stage  with 
fibrosis — similar  to  fibrosis  (cirrhosis)  of  the  liver — pancreas,  etc. 

X-rays  in  Gastric  Syphilis. — Though  some  radiologists  claim  they  can 
diagnose  gastric  syphilis  from  the  radiologic  findings  alone,  in  cases  of 
syphilitic  pyloric  stenosis,  I  believe  it  utterly  impossible.  The  history, 
physical  examination  and  serological  tests  must  all  be  considered.  On 
the  other  hand,  if  the  stomach  is  diminished  in  size  and  of  dumb-bell 
appearance  due  to  deformity  caused  by  infiltration  involving  the  middle 
or  pyloric  half  of  the  stomach,  the  pylorus  being  held  open,  so  that  the 


STOMACH    FUNCTIONS    IN    DISEASES    OF    OTHER    ORGANS  511 

Stomach  empties  or  begins  to  empty  rapidly,  with  a  slight  retention  in  the 
cardiac  end,  syphilis  can  be  diagnosed  according  to  some  of  our  radiolo- 
gists. In  other  cases  of  similar  deformity  there  is  more  marked  reten- 
tion on  account  of  involvement  of  the  pylorus  or  marked  stenosis  of  part 
of  the  infiltrated  body.  Personally  I  should  not  exclude  the  possibility 
of  cancer  unless  after  serological  tests. 

Operative  procedure  on  syphilitic  pyloric  stenosis  I  do  not  believe 
requires     more     than     gastro-enterostomy — with    subsequent  antiluetic 


Fig.  239. — Marked  six-hour  retention.  Frequent  vomiting  and  peristaltic  move- 
ments. S)T>liilitic  stenosis  of  the  pylorus,  secondary  to  syphilitic  ulcer.  Hard  fibrous 
mass  felt  at  pyloric  opening  nearly  completely  blocking  same.  Wassermann  4-I-. 
Syphilis  one  year's  duration.     Gastro-enterostomy  by  Dr.  John  J.  McGrath  (author's 


treatment.  One  does  not  see  cancer  engrafted  on  syphilitic  cirrhosis  of 
the  liver,  or  on  chronic  syphilitic  pancreatitis — though  Lane  believes  the 
latter  to  occur  as  a  result  of  his  Kinks,  while  secondary  lesions  respond  to 
active  luetic  treatment. 


(4)  Syphilitic  Cirrhosis  of  the  Stomach 

This  case  has  also  been  referred  to  under  Cancer.     The  stomach  was 
small,  hard,  and  contracted,  and  on  palpation  felt  like  a  cirrhotic  carcinoma, 


512  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

involving  the  entire  stomach.  The  patient  was  an  elderly  man,  had 
lost  considerable  weight,  and  was  suffering  from  gastric  symptoms. 

Examination  demonstrated  cirrhosis  of  the  liver  and  evidences  of  old 
syphilis.     Deficient  HCl,  or  achylia,  occurs  in  this  type. 

These  facts  show  that  the  syphilitic  history,  or  evidences  of  the  same, 
should  be  investigated  carefully  in  gastric  affections. 

Treatment  should  be  for  syphilis.  The  author  believes  that  mercury 
should  be  combined  with  the  iodid  treatment  in  these  cases.  For  example, 
mercury  salicylate  in  albolene  (lo  per  cent,  strength).  Inject  of  this  by 
hypodermic  lo  minims  every  third  or  fourth  day.  In  addition,  preferably, 
potassium  iodid,  30  grains  to  i  dram  (2.0-4.0),  should  be  given  daily  in 
divided  doses  at  meals.  Twice  the  quantity  may  be  administered  by  a 
gradual  increase.  It  may  be  necessary  to  substitute  sodium  iodid.  The 
injection  of  "606"  or  preferably  neosalvarsan  may  be  employed  followed 
by  mixed  treatment.  Appropriate  remedies  may  be  given  in  addition 
for  special  symptoms,  or  secretory  or  motor  disturbances. 

GASTRIC  CRISES  OF  TABES 

In  the  preataxic  stage  Starr  found  gastric  crises  as  the  first  symptom 
18  times  out  of  450  cases.  They  may  occur  early  in  the  course  of  the  dis- 
ease alone  or  with  laryngeal,  nephric,  rectal  and  other  crises.  In  the 
incipient  stage  the  so-called  lightening  pains  are  frequent;  they  some- 
times are  not  so  severe,  but  are  merely  a  sensation  of  soreness,  or  burning, 
leaving  an  area  of  tenderness.  They  are  most  common  in  the  legs  and 
about  the  trunk  and  follow  usually  the  dorsal  root  areas,  and  occur  at 
irregular  intervals.  There  are  paresthesia,  with  numbness  of  the  feet, 
tingling,  at  times  a  sense  of  constriction  about  the  body.  There  may  be 
the  Argyll-Robertson  pupil  which  occurs  in  the  preataxic  stage,  or  ptosis 
or  paralysis  of  the  external  muscles  of  the  eye  which  often  may  be  transient. 
This  paralytic  condition,  developing  painlessly  in  adults,  is  believed  by 
some  to  be  almost  of  as  important  diagnostic  import  as  the  Argyll-Robert- 
son pupils. 

Optic  atrophy  may  occasionally  occur  early.  Some  patients  complain 
of  difficulty  in  emptying  the  bladder.  An  early  and  important  symptom 
years  before  the  development  of  ataxia  is  the  gradual  decrease  and  finally 
loss  of  knee  and  ankle  jerks — one  before  the  other,  or  first  in  one  leg. 

Though  gastric  crises  may  be  the  first  subjective  symptom  noted  by  the 
patient  and  reported  to  the  physician,  if  a  thorough  history  is  secured  and 
a  proper  examination  is  made,  there  is  little  excuse  of  failure  to  diagnose 
the  gastric  crises  within  a  brief  period  at  least.  It  may  of  course  be  neces- 
sary to  make  the  Wassermann  or  Noguchi  tests. 

A  preexisting  vagotonia,  Eppinger  believes,  has  a  predisposing  efifect 
upon  the  occurrence  of  crises. 

Sjnnptoms. — Suddenness  of  attack  is  one  of  the  characteristics  of  this 
condition.  The  patient  is  seized  with  a  violent  pain  in  the  epigastrium 
radiating  through  the  abdomen,  back  and  limbs.  At  times  it  is  of  a 
girdle  character.  Sometimes  the  pain  begins  with  less  severity  and  gradu- 
ally increases  in  intensity.     There  may  be  cutaneous  hyperesthesia  in  the 


STOMACH    FUNCTIONS    IN    DISEASES    OF    OTHER    ORGANS  513 

epigastrium — pressure  causing  severe  pain  and  areas  of  anesthesia  may  be 
found.  The  pain  may  last  eight  to  twelve  hours,  or  even  to  two  weeks 
or  more,  but  is  not  continuous  and  the  paroxysms  may  be  of  short  duration. 
Vomiting  accompanies  the  onset  of  the  pain  both  before  and  after  meals. 
It  consists  first  of  stomach  contents,  then  of  a  glairy  mucus  secretion  at 
times  tinged  with  bile  and  occasionally  with  blood.  The  latter  may  even 
be  considerable  in  quantity.  Hypersecretion  may  accompany  the  attack 
and  large  quantities,  as  much  as  2  liters,  may  be  vomited.  As  soon  as  the 
stomach  is  empty  the  effort  of  vomiting  is  more  severe  and  the  straining 
is  added  to  the  severity  of  the  pain.  The  patients  apparently  suffer 
agony  in  many  cases.  The  strength  becomes  rapidly  reduced,  there  is 
profuse  sweating,  the  extremities  are  cold,  pulse  small  and  rapid;  respira- 
tion increased  and  there  is  intense  thirst. 

There  are  frequently  intestinal  disturbances  such  as  gaseous  distention, 
flatus,  and  continuous  diarrhea,  the  stools  containing  mucus  and  bile. 
The  patient  becomes  extremely  exhausted.  Intestinal,  rectal,  laryngeal 
and  other  crises  may  coexist.  Rarely  death  has  occurred  as  a  result  of 
collapse  or  from  exhaustion  from  the  diarrhea. 

The  attack  generally  terminates  abruptly  and  the  patient  soon  eats 
food  with  relish,  the  digestion  being  excellent,  though  in  some  recover}^ 
takes  longer. 

Physical  Examination  of  the  Abdomen. — The  epigastrium  is  retracted 
and  painful  to  pressure.  Areas  of  hyperesthesia  are  found  and  occasion- 
ally areas  of  anesthesia.  Succussion  sound  is  usually  absent.  Occasion- 
ally there  are  eructation  and  hiccoughs.     Distention  is  not  frequent. 

Gastric  Analysis. — There  may  be  variations  in  the  stomach  of  the 
same  individual  and  no  finding  can  be  considered  pathognomonic.  Some 
cases  have  hyperacidity,  others  hyperacidity  with  hypersecretion,  or  hypo- 
acidity, or  anacidity,  or  hematemesis,  or  conditions  may  vary  during  the 
crises. 

Course  and  Duration. — Crises  may  occur  six  months  apart,  or  within 
a  few  months  or  within  a  few  days  of  each  other.  The  crises  increase  as 
the  disease  advances  as  a  rule.  Duration  may  vary  from  twenty-four  to 
forty-eight  hours,  or  may  be  prolonged  several  weeks. 

Differential  Diagnosis. — One  must  differentiate  these  crises  from  hepatic 
colic,  nephritic  colic,  Dietl's  crises,  lead  colic,  attacks  of  hypersecretion 
and  hysterical  crises.  The  heavy  blue  line  on  the  gums,  neuritis,  wrist 
drop  and  excessive  granular  basophilic  degeneration,  suggest  lead  colic 
and  the  hysterical  crises  are  less  violent.  The  symptoms  of  the  other  con- 
ditions have  been  already  thoroughly  described. 

Treatment. — Acute  Attack. — Abolition  of  food  as  at  first  indicated 
and  the  remedies  employed  in  acute  gastritis  for  vomiting. 

One  or  two  doses  of  antipyrin,  gr.  xv,  or  acetanilid  guarded  with 
caffein,  gr.  i,  can  be  tried  for  the  pain.  Morphin,  gr.  }i,  by  hypodermic 
or  codein,  gr.  }4,  by  hypo  njay  be  required.  They  should  be  used  by  phy- 
sician or  nurse  only.  Hyoscyamin,  gr.  Hoo>  or  hyoscin,  gr.  Koo>  can  be 
tried  or  cannabis  indica  or  the  bromids.  If  there  is  hyperacidity  or 
hypersecretion  or  spasm,  alkalis  can  be  given  and  also  belladonna. 

Lumbar  puncture  has  relieved  the  acute  attack.     Foerster  has  recom- 

33 


514  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

mended  rhizotomy,  i.e.,  resection  of  the  posterior  spinal  nerve  roots  from 
the  twelfth  to  the  fifth  dorsal.  High  pressure  sometimes  occurs  between 
attacks  and  for  this  the  nitrites  or  aconite  tincture,  gtts.  8  (35  per  cent.), 
t.i.d.  is  advised.  After  the  attack,  syphilis  should  receive  treatment. 
Salvarsan  or  neosalvarsan  should  be  infused  intravenously  or  injected 
into  the  spinal  canal  and  this  should  be  followed  by  mixed  treatment. 


PART  III 
DISEASES  OF  THE  INTESTINES 


CHAPTER  XX 


METHODS  OF  EXAMINATION  OF  THE  INTESTINES;  EXAMINA- 
TION OF  THE  FECES;  MECHANICAL  PROCEDURES 

Special  Interrogation. — We  presuppose  that  the  method  of  interroga- 
tion of  the  patient,  as  described  in  Part  I,  has  been  carried  out.  Disease 
of  the  stomach  may  produce  secondary  intestinal  symptoms,  and  hence  the 
condition  of  this  organ  must  be  inquired  into,  and  in  most  cases  the  func- 
tions examined. 

Inquire,  furthermore,  whether  abdominal  pains  are  present,  and  also 
their  position.  In  the  right  iliac  fossa  they  suggest  appendicitis  or  catarrh 
of  the  cecum;  in  the  left  iliac  fossa,  disturbances  of  the  descending  colon 
or  sigmoid. 

With  rectal  pain,  inflammation  in  that  region  is  probable,  while  pains 
near  the  navel  usually  originate  in  the  small  intestine.  Pains  of  short 
duration  and  sharp  in  character  are  generally  due  to  colic,  and  are  fol- 
lowed and  relieved  by  the  passage  of  flatus  or  feces.  They  often  shift  from 
one  region  to  another.  Pains  of  long  duration  are  usually  from  some 
organic  lesion,  such  as  ulcer  or  from  some  affection  of  the  sensory  nerves. 

Abnormal  sensations,  such  as  feelings  of  heat  or  cold,  may  be  experi- 
enced over  different  regions  of  the  abdomen. 

Tenesmus  is  present  in  dysentery  and  in  many  rectal  affections.  The 
time  of  the  pain,  whether  immediately  after  meals  or  later,  or  during  the 
night  or  in  the  early  morning,  is  important. 

The  stool  should  be  investigated — whether  constipation,  diarrhea,  or 
alternating  conditions  exist,  the  number  of  movements,  time  of  appear- 
ance, odor,  color,  and  characteristics,  as  to  whether  mucus,  blood,  bile, 
pus,  or  undigested  food  are  present. 

Do  climatic  changes  or  mental  excitement  influence  the  bowel  action, 
or  are  headache,  dizziness,  or  exhaustion  associated  with  the  movements? 
Is  there  distention  of  the  abdomen  with  gas,  localized  or  general?  When 
does  it  appear?  Is  rumbling  (are  borborygmi)  present?  Do  belching  of 
wind  or  passage  of  gas  from  the  bowel  occur,  and  does  this  give  relief? 

Total  absence  of  flatus  is  important.  Occurring  with  obstinate  con- 
stipation, it  would  then  suggest  obstruction. 

Continuous  vomiting  associated  with  intestinal  symptoms  suggests 
obstruction.  With  acute  symptoms,  the  temperature  should  be  taken 
immediately. 

SIS 


5l6  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

PHYSICAL  EXAMINATION  OF  THE  INTESTINES 

The  reader  is  referred  to  Chapter  IV  for  general  methods. 

Inspection. — The  retracted  or  trough-shaped  abdomen  occurs  in 
stricture  of  the  esophagus  or  cardia,  basilar  meningitis,  lead-poisoning, 
and  with  long-continued  inanition.  The  peculiar  contour  of  enteroptosis 
has  been  described — the  concave  epigastrium,  sulcus  between  the  recti 
above  the  umbilicus,  and  the  pot-belly  below. 

On  distention  of  the  normal  colon  with  gas  (CO2),  the  ascending  and 
descending  portions  are  seen  as  elongated  swellings  in  the  lateral  regions, 
and  the  transverse  colon  at  or  just  above  the  umbilicus. 

Protrusion  of  the  abdomen  may  be  over  a  definite  area,  or  over  the  entire 
surface.  It  may  assume  the  shape  of  a  rounded  hemisphere,  or  oval, 
slightly  flattened,  especially  in  atonic  conditions  of  the  intestines  and  in 
hysteria.  Marked  uniform  distention  with  tense  abdominal  walls,  absence 
of  respiratory  abdominal  movements,  and  increased  thoracic  respiration 
are  present  in  peritonitis.  There  may  be  a  general  bloating  with  atony, 
but  there  is  not  the  marked  tension  of  the  abdominal  walls,  and  the  other 
symptoms  are  absent. 

With  ascites,  the  abdomen  is  evenly  protuberant  above,  with  the  center 
somewhat  flattened,  while  the  lateral  and  dependent  parts  bulge  somewhat 
in  the  recumbent  position;  change  of  posture  alters  the  shape  of  the  ab- 
domen.    This  applies  to  the  milder  types. 

With  marked  distention,  as  with  meteorism,  the  enlargement  is  uni- 
form. There  is  no  bulging  in  any  special  location,  except  that  the  anterior 
portion  is  more  prominent  and  change  of  position  has  no  effect.  Palpa- 
tion aids  under  these  conditions. 

There  may  be  protrusion  of  the  abdomen  in  cases  of  neoplasm,  in  fecal 
accumulation,  and  occasionally  in  abscess,  as  of  the  appendix,  from  diver- 
ticulitis, or  other  intra-abdominal  suppuration. 

Hernial  protrusions  at  the  umbilicus  or  in  the  inguinal  regions,  may  be 
observed. 

In  patients  with  thin  abdominal  walls,  small  sausage-shaped  protru- 
sions are  occasionally  visible,  which  change  their  shape  and  position. 
This  is  due  to  peristalsis  of  the  small  intestine,  occurs  with  no  pain,  and 
denotes  no  morbid  condition. 

Similar  waves  may  appear  periodically  and  annoy  the  patient  when 
caused  by  nervous  influences. 

There  are  sometimes  violent  contractions  (peristaltic  unrest)  of  the 
small  intestine  visible,  caused  by  stenosis  or  obstruction.  If  it  is  near  the 
ileocecal  valve,  the  swollen  and  moving  coils  of  intestine  lie  one  above  the 
other  in  the  central  part  of  the  abdomen  (ladder  pattern).  Intense  pain 
accompanies  these  movements. 

Marked  distention  may  be  visible  in  the  course  of  the  colon  (in  the 
circumference  of  the  abdomen),  and  if  associated  with  visible  peristaltic 
contractions  of  the  large  intestine,  passing  along  it  from  right  to  left,  it  is 
diagnostic  of  partial  or  total  obstruction  of  the  large  bowel. 

In  some  cases  a  recurring  protuberance  is  noted,  disappearing  with  a 
loud  sound.     This  is  probably  near  the  point  of  stenosis. 


INSPECTION    OF  RECTUM — PROCTOSCOPY    AND   SIGMOIDOSCOPY      517 

INSPECTION  OF  THE  RECTUM— PROCTOSCOPY  AND  SIGMOIDOSCOPY 

The  anus  can  be  inspected  by  having  the  patient  lie  on  his  side  with 
thighs  and  knees  flexed,  and  his  back  toward  the  examiner.  The  buttocks 
should  be  held  apart  with  the  hands.  The  patient  may  be  instructed  to 
bear  down  as  if  to  defecate.  This  is  often  an  aid  to  the  examination. 
Hemorrhoids,  condylomata,  skin  eruptions,  rectal  prolapse,  occasionally 


Kelly's  short  rectal  speculum. 


polypi  which  may  extrude,  abscess  (periprocititis)  occasionally  thread 
worms,  rarely  intussusception,  fissures,  and  fistulae  may  be  discovered. 

For  inspection  of  the  rectum  the  introduction  of  a  speculum  (procto- 
scope) is  necessary.  Palpation  of  the  rectum  (described  later)  should  be 
carried  out,  before  the  introduction  of  the  proctoscope. 


Fig.  241. — Kelly's  standard  rectal  speculum. 

Proctoscopy. — Various  instruments  have  been  devised,  notably  those 
of  Howard  Kelly,  Roberts,  Sims,  Kelsey,  Gant,  and  J.  P.  Tuttle  (Figs. 
240-248). 

Roberts'^  glass  speculum  may  be  of  value  for  the  examination  of  a 
patient  with  an  irritable  anus.  The  instrument  does  not  distort  the  parts 
and  can  be  readily  introduced.     There  is  a  lateral  opening  for  the  purpose 

*  Jour.  Amer.  Med.  Assoc,  Jan.  8,  1910. 


5i8 


DISEASES    OF   THE   STOMACH    AND   INTESTINES 


of  making  an  application  or  employing  a  probe.  There  is  a  mirror  so 
arranged  that  it  can  be  pushed  in,  withdrawn,  or  rotated,  and  so  give  a 
view  of  the  entire  wall  at  a  varying  depth.  It  is  necessary  to  use  reflected 
light  from  a  head-mirror  or  an  electric  head-light  (Fig.  242). 


Fig.  242. — Roberts'  glass  anal  speculum. 

The  bowels  should  preferably  be  thoroughly  evacuated  by  enema  before 
the  examination.  If  the  region  is  sensitive,  a  few  drops  of  a  2  to  5  per 
cent,  cocain  solution  can  be  injected  inside  and  along  the  sphincters  with 
a   narrow-pointed   rubber   syringe.     A   suppository   containing   opium, 


Fig.  243. — Kelly's  proctoscope  (J^  actual  size). 

I  grain  (0.065),  with  extract  of  belladonna,  ^  grain  (0.022),  or  cocain, 
H  grain  (0.008),  can  be  substituted. 

Tuttle's  pneumatic  proctoscope  is  a  valuable  instrument.     There  is  an 
electric  lamp  at  the  end  of  the  inspection  tube  and  an  arrangement  for 


Fig.  244. — Kelly's  sigmoid  speculum. 

inflation  of  the  rectum,  so  that  it  can  be  distended  with  air  at  the  time  of 
examination 

With  other  specula,  a  head-mirror  with  electric-light  attachment  is 
most  convenient,  though  an  ordinary  light  can  be  arranged.  The  patient 
lies  on  the  side,  with  thighs  and  knees  flexed,  with  back  toward  examiner, 
or  the  legs  can  be  elevated  on  a  crutch,  or  in  some  cases  the  knee-chest 


INSPECTION    OF    RECTUM PROCTOSCOPY    AND    SIGMOIDOSCOPY       519 

position  can  be  assumed.  The  external  sphincter  as  well  as  the  speculum 
should  be  lubricated  with  sweet  oil  or  vaselin,  to  render  introduction  more 
easy. 

Sigmoidoscopy. — A  long  speculum  (sigmoidoscope)  may  be  required 
for  examination  oi  the  sigmoid  (Figs.  250  and  251).  Among  the  best 
sigmoidoscopes  are  those  of  Kelly,  Tuttle,  and  H.  Strauss;  Beer^  reports 


Fig.  245. — Sims'  rectal  speculum. 

a  modification  of  the  latter.  My  own  preference  is  the  pneumatic  sig- 
moidoscope of  Tuttle  or  Strauss.  Strauss'  instrument  possesses  the 
advantage  that  if  the  lamp  becomes  dirty,  it  can  be  removed  and  cleaned 
without  taking  out  the  entire  instrument,  and  also  has  a  pneumatic 
inflator,  as  has  Tuttle's  sigmoidoscope.  Tuttle  introduces  the  instrument 
in  the  Sims  posture,  while  Strauss  advocates  the  knee-chest  position  as  in 


Fig.   246. — Kelsey's  speculum. 

Fig.  249.  Sigmoidoscopy  should  be  performed  by  direct  vision.  The 
instrument  should  be  warmed  and  thoroughly  lubricated.  It  should  be 
introduced  with  the  obturator  for  about  4  inches  along  the  sacral  curve, 
keeping  the  end  of  the  instrument  toward  the  sacrum.  The  obturator 
should  then  be  removed  and  the  light  turned  on.  The  inflating  instru- 
ment is  best,  as  by  sUght  puffs  of  air  with  the  bellows,  the  folds  of  the  bowel 
are  pushed  aside.  The  operator  should  look  for  the  lumen  of  the  bowel  and 
1  N.  Y.  Med.  Rec.,  Feb.  11,  191 1. 


520  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

gently  follow  it.  The  bowel  passes  back  along  the  sacral  curve  and  then 
turns  sharply  forward  over  the  prominence  of  the  sacrum  and  at  this  point 
the  tip  of  the  instrument  must  be  carried  forward.  At  the  recto-sigmoidal 
juncture,  there  is  a  fold  of  mucosa  somewhat  like  Houston's  valves  which 
may  catch  the  tip  of  .the  instrument.  Usually  the  sigmoid  passes  to  the 
left  after  the  recto-sigmoid  junction,  though  this  is  not  invariable. 


Fig.  247. — Gant's  examining  speculum. 

One  must  avoid  entering  the  cul-de-sac  of  the  rectum  which  extends 
up  and  behind  this  junction.  Force  should  never  be  used.  The  procedure 
is  somewhat  more  difficult  in  women — particularly  with  enteroptosis.  If 
the  rectum  is  very  sensitive  a  weak  cocain  injection  gr.  \i  in  water  5iv 
may  be  given  as  preliminary.  Occasionally  anesthesia  may  be  required. 
In  Fig.  252,^  arrow  No.  i  shows  the  direction  of  the  apparatus  at  the 


•     Fig.   248. — Gant's   hinged   speculum. 

beginning  of  the  entry;  arrow  No.  2,  the  position  at  the  view  of  the  ampulla 
recti,  and  arrow  No.  3,  the  direction  at  the  time  of  entering  the  flexure  of 
the  colon  (sigmoid).  The  presence  of  blood,  or  blood  and  pus  in  the  stools, 
or  progressive  constipation  are  indications  for  examination  of  the  rectum 
and  sigmoid.  One  should,  of  course,  exclude  ulcerations  of  any  portion  of 
^  S.  Kelen,  Pester  Medizinische-chirurgische  Presse,  April  17,  1904. 


INSPECTION   OF   RECTUM — PROCTOSCOPY   AND    SIGMOIDOSCOPY      52 1 

the  small  intestine.  When  rectal  examination  (proctoscopy)  fails  to 
afford  the  desired  information,  sigmoidoscopy  is  indicated.  One  should, 
of  course,  acquire  all  possible  information  by  abdominal  palpation  and 
other  methods.  • 


Fig.  249. — Sigmoidoscopic  examination  of  the  colon  with  the  patient  in  the  genupectoral 

position. 

Palpation. — The  technic  of  simple  and  reinforced  palpation  has  been 
described  in  Chapter  IV. 

The  cecum,  parts  of  the  ascending  and  descending  colon,  the  transverse 


B 

Fig.  250. — A,  Tuttle's  pneumatic  proctosigmoidoscope.  Two  lengths — rectal  4 
inches,  sigmoid  10  inches — with  window  attachment  to  make  instrument  air-tight  for 
bowel  inflation;  B,  Tuttle's  sigmoidoscope  with  Mercier  curve. 

colon,  and  the  sigmoid  flexure  are  often  accessible  to  palpation,  but  not  as 
readily  so  in  obese  or  in  muscular  subjects.  Fecal  accumulation,  tumors, 
thickening  of  the  gut,  or  purulent  collections  connected  with  the  intestine 
can  often  thus  be  recognized. 


522 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


An  uneven  protuberant  surface  is  characteristic  of  malignant  growth, 
while  an  even  surface  is  more  often  found  in  benignant  neoplasm  or  intus- 
susception. Volvulus  occurs  usually  in  the  sigmoid.  A  fecal  accumula- 
tion will,  as  a  rule,  "pit"  on  pressure  (give  a  doughy *f eel).     Hard  scybalae 


^ 


251. — Strauss'  sigmoidoscope. 


occasionally  feel  like  marbles  under  the  fingers,  but  can  be  moved  or 
slightly  indented.  Sometimes  when  raising  the  fingers  from  palpating, 
there  may  be  a  crepitating  or  sticky  sensation,  or  the  intestinal  wall  can 
be  felt  to  slip  oflF  from  the  fecal  mass.  This  symptom  was  first  described 
by  Gersuny.* 


Fig.  252. — Sigmoidoscopy  (knee-chest  posture,  Strauss):  Arrow _  i  shows  the 
direction  of  the  apparatus  at  the  beginning  of  entry;  arrow  2,  the  position  at  the  view 
of  the  ampulla  recti;  arrow  3  shows  the  manner  of  entering  the  flexure. 

Gurgling  occurs  in  typhoid  on  palpation  in  the  right  iliac  fossa,  but  is 
not  diagnostic. 

Tenderness  or  pain  on  pressure  can  be  readily  determined  by  palpation, 
and  are  suggestive  of  inflammatory  processes  or  ulceration.     There  may 

*  Wiener  klin.  Wochens.,  1891,  No.  4. 


INSPECTION   OF   RECTUM — PROCTOSCOPY   AND   SIGMOIDOSCOPY      523 

be  the  general  tenderness  of  acute  intestinal  inflammation  or  the  acute 
pain  and  tenderness  of  peritonitis,  either  localized  or  general. 

Circumscribed  pain  on  pressure  may  be  present  at  McBurney's  point 
(iH  to  2  inches  to  the  inner  side  of  the  anterosuperior  spine  of  the  right 
ileum)  on  a  line  drawn  from  this  process  to  the  umbilicus. 

Morris'  point  and  the  lumbar  ganglia  (referred  to  under  Appendicitis), 
Robson's  point,  Murphy's  point  (gall  bladder),  tenderness  at  the  costo- 
vertebral angles,  and  the  tender  points  for  duodenal  and  gastric  ulcer 
should  be  tested  for. 

With  ulceration  of  the  bowels,  there  may  be  circumscribed  areas  very 
sensitive  to  pressure;  with  hysteric  manifestations  there  are  often  sensitive 
spots  complained  of  in  the  abdomen,  as,  for  example,  in  mucous  colic. 
By  palpating  simultaneously  two  distinct  points,  the  supposed  painful 
area  and  another  region,  with  the  different  hands,  and  at  the  same  time 
distracting  the  patient's  attention  by  conversation,  one  often  finds  an 
absence  of  true  tenderness  at  the  supposed  seat  of  pain. 

Muscular  rigidity  shows  peritonitic  involvement.  It  may  be  localized, 
as  of  the  right  rectus  in  the  region  of  the  appendix  or  gall-bladder,  or  over 
the  left  rectus,  as  in  diverticulitis  or  phlegmonous  gastritis,  or  in  abscess 
of  the  left  lobe  of  the  liver.     General  rigidity  shows  general  peritonitis. 

Splashing  Sotind  (Clapotage,  Succussion). — If  the  intestines  contain 
liquid  material  and  gas,  tapping  over  them  with  the  fingers  wiU  at  times 
produce  the  splashing  sound.  The  method  of  differentiation  between 
stomach  and  intestinal  splash  has  been  described  under  "Splash  of  the 
Stomach"  in  Chapter  V. 

In  the  small  intestine  clapotage  can  usually  only  be  obtained  in  the 
dilated  portion  of  the  gut  above  a  stricture.  It  is  not  uncommon  in  the 
large  intestine,  and  can  be  most  determined  in  the  sigmoid  flexure,  caput 
coli,  and  the  transverse  colon.  In  case  of  atony  of  the  bowel  it  is  quite 
frequently  present,  also  in  the  relaxed  abdomen  of  enteroptosis,  and  often 
in  patients  with  hysteric  manifestations. 

Boas^  first  suggested  injecting  into  the  bowel  i  pint  (500  c.c.)  or  more 
of  water  and  then  examining  for  the  splash  along  the  colon.  It  should  be 
given  with  hips  elevated.  The  splash  will  first  be  secured  in  the  sigmoid, 
and  by  turning  the  patient  on  the  right  side  it  can  at  times  be  produced 
in  the  transverse  colon  and  in  the  cecal  region. 

It  is  possible  to  administer  an  enema  of  moderate  size  and  cause  it  to 
gravitate  to  the  caput  coli,  by  the  method  of  rotation  described  under 
Enteroclysis.  By  the  splash  one  can  determine  whether  an  injection  given 
for  dysentery  has  passed  through  the  entire  colon  to  the  cecum. 

In  atony  of  the  bowel,  Boas  produced  the  splash,  even  after  the  injec- 
tion of  only  6  to  10  ounces  (200-300  c.c.)  of  water.  The  position  of  the 
colon  can  be  determined  by  the  splashing  sound  when  it  is  present;  it  can 
be  produced  artificially  by  the  injection  of  water  into  the  bowel,  and  be 
thus  employed  for  locating  position  of  the  intestines.  A  little  Vichy, 
4  ounces  (125  c.c),  can  be  added  to  the  injection  to  increase  the  amount  of 
gas. 

*  Diagnostik   und  Therapie  der   Magenkrankheiten,   1897. 


524 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Palpation  of  the  Rectum. — This  procedure,  the  author  believes,  should 
be  carried  out,  before  inspection  with  the  proctoscope.  The  rectum  is 
preferably  palpated  with  the  index-finger.  Soap  should  be  placed  under 
the  edge  of  the  nail  to  prevent  fecal  material  lodging  therein,  and  the 
finger  lubricated  with  vaselin  or  olive  oil.  It  is  well  to  grease  the  external 
sphincter,  as  it  renders  entrance  of  the  finger  easier.  It  is  more  cleanly  to 
encase  the  finger  with  a  thin  rubber  cot,  or  to  employ  a  rubber  glove,  well 
lubricated. 

The  patient  lies  on  the  side,  with  knees  flexed  and  the  back  to  the 
exan'iiner,  or  he  may  be  in  the  knee-chest  position,  or  stand  with  the  waist 
flexed — leaning  forward  over  a  chair  and  bearing  down  as  if  to  defecate. 
Hemorrhoids,  polypi,  low-seated  stricture,  tender  points  or  a  pit-like  feel 
suggestive  of  ulcer  or  fissure,  malignant  growths,  rectal  prolapse,  abscess, 
fecal  obstruction,  foreign  bodies,  and  intussusception  are  often  within  reach 
of  the  examining  finger.  The  prostate  and  seminal  vesicles,  or  uterus 
with  the  tubes  and  ovaries  should  be  palpated  during  the  examination.  A 
gum-boil  like  feel  is  suggestive  of  a  submucous  fistula  and  cord-like  infiltra- 
tion, of  fistulous  tracks.     The  sacrum,  coccyx  and  the  condition  of  the 


Fig.  253. — A,    Soft    rectal    bougie;    B,    cylindric    bougie. 


sphincter  should  be  examined.  If  the  difficulty  is  located  beyond  reach 
of  the  palpating  finger,  inspection  with  the  proctoscope  or  sigmoidoscope 
will  give  the  required  information.  Simon's  method  of  dilating  the  sphinc- 
ter under  anesthesia  and  passing  the  hand  and  arm  into  the  bowel,  for  the 
purpose  of  palpation,  is  a  most  dangerous  procedure. 

Vaginal  Examination. — The  author  recommends  that  in  every  case  the 
female  pelvic  organs  should  be  also  examined.  Irritation,  or  inflammation 
of  the  pelvic  organs  may  have  a  reflex  effect  in  producing  irritation  of  the 
rectum  and  vice  versa.  Traumatism  or  inflammation  of  the  one  are  liable 
to  extend  to  the  other  directly  or  through  their  lymphatic  connections. 
An  overweighted  uterus  may  sag  down  on  the  rectum  and  produce  hemor- 
rhoids. Many  other  examples  can  be  given.  Pelvic  and  sacral  pains, 
reflex  pains,  and  irregularity  of  functions,  in  fact,  very  similar  symptoms, 
may  occur  from  either  rectal  or  pelvic  disease.  The  primary  cause  should 
be  carefully  investigated,  and  hence  the  additional  value  of  a  vaginal 
examination. 


INSPECTION    OF    RECTUM PROCTOSCOPY    AND    SIGMOIDOSCOPY       525 

Palpation  of  the  Rectum  by  Sounds. — This  is  indicated  when  there  is 
suspicion  of  stricture  in  the  bowel  not  accessible  to  the  fingers.  Soft 
rectal  tubes  of  various  caliber  may  be  employed.  When  the  obstruction 
stops  the  passage  of  the  tube,  a  mark  is  made  at  the  external  sphinc- 
ter, so  that  the  distance  of  the  stricture  up  the  bowel  can  be  estimated. 
Smaller  tubes  are  then  employed  until  one  can  pass  the  obstruction.  Its 
cahber  is  thus  estimated.  The  ordinary  soft  flexible  rectal  or  colon-tube 
is  the  safest  for  diagnostic  purposes  in  the  hands  of  the  general  practitioner. 

In  Fig.  253,  A  and  B,  are  shown  an  olive-pointed  flexible  and  a  cylindric 
bougie.  The  latter  is  somewhat  stiff  and  can  be  softened  in  hot  or  boiling 
water  before  use.  This  last  is  also  employed  for  dilatation  of  the 
stricture. 


Fig.  254. — Auscultatory  percussion  of  the  colon. 

Kuhn's  metal  spiral  tube  is  of  no  advantage.  Care  should  be 
exercised  if  stiff  tubes  are  employed. 

Percussion  should  be  gentle.  Over  empty  intestinal  coils,  or  those 
containing  gas  or  air,  a  tympanitic  sound  results,  which  is  louder  over 
the  lange  than  over  the  small  bowel.  As  there  may  be  considerable  dis- 
tention of  the  small  intestine,  it  is  sometimes  difficult  to  delimit  the  large 
intestine  by  simple  percussion.  If  the  colon  is  emptied  by  enema,  and 
then  distended  artificially  with  air  or  carbonic  acid  gas,  the  procedure  is 
much  easier. 

Intestinal  coils  which  are  filled  with  liquid  or  solid  material  give  dul- 
ness  on  percussion.  With  meteorism  there  is  tympanites  of  a  deeper 
pitch  than  normal,  and  sometimes  there  is  a  metallic  sound  with  auscul- 


526 


DISEASES    OF    THE    STOMACH   AND    INTESTINES 


tatory  percussion.  The  meteorism  may  be  localized  or  general.  If 
local,  in  connection  with  visible  peristalsis,  intestinal  stenosis  is  at  once 
suggested.  With  local  meteorism  there  will  be  dull  areas  elsewhere;  with 
general  meteorism  the  entire  abdomen  is  symmetrically  distended,  the 
anterior  portion  being  most  protruded,  and  there  is  the  diffused  tym- 
panitic note  of  the  peculiar  type  noted,  and  dulness  over  the  region  of  the 
liver  and  spleen  may  disappear.  With  ascites,  percussion  shows  dulness 
in  the  lower  lateral  regions  of  the  abdomen  and  tympanites  in  the  middle. 
The  sounds  change  on  altering  the  position  of  the  patient  (turning  him 
on  his  side).  The  intestines  ride  up  on  the  fluid,  and  the  upper  flank, 
previously  dull  when  in  the  dorsal  position,  is  now  tympanitic. 

Fecal  accumulation,  tumors,  and  abscesses  give  dulness  on  percussion. 

Auscultatory  Percussion. — This  is  the  best  method  of  determining  the 

position  of  the  colon.     If  the  small 


1 


intestine  is  excessively  distended,  it 
is  difficult  to  differentiate  the  per- 
cussion sounds.  It  may  be  neces- 
sary to  empty  the  colon  by  enema 
or  irrigation  and  then  inflate  with 
air  or  CO2.  Place  the  stethoscope 
at  the  circle  (Fig.  254)  over  the 
cecum;  begin  percussion  midway 
between  the  umbilicus  and  sym- 
physis, and  percuss  to  the  right, 
to  the  left,  and  upward,  in  the  di- 
rection of  the  arrows,  until  in  each 
direction  the  greater  intensely  al- 
tered quality  and  heightened  pitch 
show  that  the  inner  border  of  the 
colon  has  been  reached.  These 
points  can  be  marked  on  the  ab- 
domen with  a  pencil.  Then  per- 
cuss in  the  epigastric  region  (mid- 
way between  the  ensiform  and  um- 
bilicus) downward,  and  from  the  lateral  lumbar  regions  inward.  The 
changes  in  pitch,  quality,  etc.,  should  be  marked,  and  thus  the  outer 
limits  of  the  transverse  ascending  and  descending  portions  of  the  colon 
are  determined. 

The  scratch  method  of  auscultatory  percussion  may  be  carried  out 
in  the  same  lines. 

Stengel  claims  that  by  auscultatory  percussion  it  is  possible  to  de- 
termine that  a  tumor  found  to  lie  in  the  course  of  the  intestine  originates 
in  the  wall  of  the  colon.  In  Fig.  255,  C  represents  the  tumor;  the  circle 
O,  the  stethoscope  placed  over  the  colon  near  the  tumor;  B,  percussion 
note  over  small  intestine;  A,  percussion  over  normal  large  intestine  near 
the  stethoscope. 

First  percuss  directly  over  the  tumor,  then  toward  it  from  every 
direction.     The  note  over  tumor,  C,  if  it  is  connected  with  the  colon. 


Fig.  255. — Differential  percussion. 


INSPECTION    OF    RECTUM — PROCTOSCOPY   AND    SIGMOIDOSCOPY      527 

resembles  the  percussion  note  at  A  (colon)  more  closely  than  does  per- 
cussion note  at  B  (small  intestine)  resemble  note  at  A  (colon). 

Auscultatory  Inflation  of  the  Colon. — Musser's^  Method. — The 
bowels  are  well  emptied  by  a  cathartic  and  subsequent  enema.  A  thick, 
rather  stiff  tube  is  inserted  well  into  the  rectum.  It  should  be  sufficiently 
long  to  project  20  to  24  inches  outside  the  rectum  so  that  it  be  can 
be  brought  outside  the  blanket  covering  the  patient  without  exposure  of  the 
latter.  An  air  bulb  is  attached  to  the  distal  end.  With  the  patient 
in  the  dorsal  position  and  the  abdomen  uncovered,  the  stethoscope  is 
placed  on  the  lowest  part  of  the  abdomen.  The  bulb  is  squeezed  and  the 
stethoscope  moved  upward  an  inch  or  so.  This  procedure  is  continued 
along  the  course  of  the  descending  colon  until  the  transverse  colon  is 
reached,  when  the  character  of  the  inflation  sound  is  changed.  While 
it  was  formerly  a  muffled  distant  sound,  it  now  becomes  clearer  and  louder 
with  a  rather  metallic  tone,  while  the  passage  of  the  air  can  be  distinctly 
heard.  The  same  procedure  is  repeated  in  every  direction  and  the  first 
change  of  tone  is  marked  on  the  skin  with  a  dermographic  pencil.  In  this 
way  the  entire  outline  of  the  colon  is  marked  off  on  the  abdomen.  This 
patient  then  stands  and  the  outline  in  this  position  is  made.  Usually  there 
is  a  change  in  the  inflation  tone  over  the  sigmoid  flexure,  the  descending 
and  transverse  colon.  The  tone  is  not  always  clear  in  the  region  of  the 
hepatic  flexure  and  the  ascending  colon,  but  becomes  usually  very  distinct 
over  the  cecum.  Abnormal  variations  are  readily  appreciated,  such  as 
redundant  sigmoid,  ptosed  colon,  dilated  and  movable  cecum,  etc.  Partial 
obstruction  Musser  states  may  be  diagnosed  by  this  method  through  the 
subjective  sensations  of  the  patient.  Normal  patients  suffer  moderate 
distress  from  distention,  which  is  relieved  by  removing  the  bulb  and  allow- 
ing the  escape  of  air.  If  there  is  mechanical  obstruction,  the  air  is  not 
promptly  passed,  but  is  retained  for  some  time,  and  there  are  sharp, 
colicky,  cramp-like  pains  in  the  region  of  suspected  obstruction  due  to 
increased  peristalsis  from  retained  air.  The  pain  is  not  relieved  until 
most  of  the  air  is  passed. 

Auscultation. — ^This  is  not  of  great  significance  in  intestinal  diseases. 
Palpation  may  elicit  a  gurgling  noise  in  the  right  iliac  fossa,  formerly 
thought  to  be  pathognomonic  of  typhoid,  but  it  is  found  in  many  other 
conditions.  Gurgling  sounds  (borborygmi)  are  at  times  heard.  They 
may  be  due  to  fermentative  processes  or  occur  in  neuroses,  and  are  not 
specially  significant. 

The  entire  absence  of  intestinal  sounds  may  be  significant  of  in- 
testinal paresis.  If  the  latter  is  due  to  peritonitis,  cardiac  and  respiratory 
sounds  may  be  audible  over  the  entire  abdomen.  Friction  sounds  from 
perisplenitis  or  perihepatitis  may  rarely  be  auscultated.  With  chronic 
stenosis  very  loud  noises  are  at  times  heard,  caused  by  the  sudden  passage 
of  fluid  and  gas  through  the  stricture  under  pressure. 

Splashing  sounds  are  at  times  distinguishable  in  the  enlarged  bowel 
above  the  stricture. 

*  N.  Y.  Med.  Jour.,  June  27,  1914. 


528  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

TRANSILLUMINATION  OF  THE  INTESTINES 

This  method  was  first  suggested  by  Einhorn,^  and  further  practised 
by  Heryng  and  Reichmann.^ 

Einhorn's  technic  is  as  follows:  A  high  enema  or  irrigation  of  the 
bowel  is  first  given.  A  quart  of  water  is  later  injected  per  rectum,  and 
the  illuminator,  very  similar  to  the  gastrodiaphane,  is  inserted  and  gradu- 
ally pushed  up  the  intestine.  The  examination  must  be  made  in  a  dark 
room.  Experiments  were  carried  out  by  the  author  with  specially  devised 
illuminators  at  the  Manhattan  State  Hospital. 

As  the  average  adult  rectum  is  8  inches  long,  the  sigmoid  flexure  173-^ 
inches,  and  allowance  must  be  made  for  the  sphincters,  it  requires  an 
instrument  at  least  30  inches  in  length  to  pass  through  the  sigmoid  into 
the  descending  colon.  The  '30-inch  instruments,  with  which  I  experi- 
mented, on  almost  every  occasion  caught  and  coiled  back,  and  rarely  did 
I  succeed  in  securing  transillumination  of  the  lowest  part  of  the  sigmoid, 
and  even  then  the  light  was  so  faint  that  it  was  entirely  unsatisfactory.  . 

Inflation  of  the  bowel  with  water,  with  fluorescein  solution,  and  with 
air  were  all  tried  before  passage  of  the  Hght,  as  were  various  positions  of 
the  patient. 

The  experiments  demonstrated  practically  the  impossibility  of  passing 
a  flexible  instrument  or  tube  through  the  sigmoid.  The  sigmoid  is  quite 
movable,  and  Howard  Kelly  has  shown  that  the  colon-tube  readily  pushes 
it  up.  My  experiments  demonstrated  visually  the  impossibility  of  passing 
the  long  colon-tube  through  the  sigmoid  flexure,  and  showed  that  trans- 
illumination of  the  sigmoid  has  not  been  sufficiently  certain  to  prove  of 
practical  value. 

RontgenRays  (X-rays). — For  examination  of  the  intestines  the  «-rays 
are  of  value  for  the  following  conditions: 

The  determination  of  the  presence  of  a  foreign  body  in  the  intestinal 
tract,  accurately  locating  its  position,  and  hence  the  site  for  operation. 

Einhorn^  has  recommended  the  internal  administration  of  bismuth 
subnitrate  in  watery  solution  to  locate  the  constriction  in  acute  intestinal 
obstruction  with  the  aid  of  the  a;-rays.  The  delay  necessitated  would  be 
dangerous. 

For  locating  the  seat  of  chronic  intestinal  occlusion  the  method  is  of 
service. 

An  ounce  (30.0)  of  bismuth  subnitrate  or  bismuth  subcarbonate  or 
barium  sulphate  preferably,  can  be  administered  in  12  ounces  (375  c.c.) 
of  milk  or  water  or  zoolak  by  preference  and  about  twenty -four  hours  later 
examination  should  be  made  with  the  x-rays.  With  the  fluoroscope 
or  by  a  radiograph  one  would  see  a  distended  area  of  intestine  filled  with 
bismuth,  a  region  below  with  apparently  no  bismuth  or  a  trace  (the  point 
of  stenosis),  and  below  this  a  small  amount  of  bismuth  that  had  passed 
through  the  stricture.  K  the  stricture  is  apparently  in  the  large  intestine, 
a  check  test  can  be  made  as  suggested  by  Einhorn.* 

^  N.  Y.  Med.  Montasschr.,  Nov.,  1889. 
2  Therapeutische  Montashefte,  1892. 
'  N.  Y.  Med.  Jour.,  May  18,  1907. 
« Ibid. 


TRANSILLUMINATION  OF   THE  INTESTINES  529 

A  few  days  later,  when  the  bowel  is  free  from  bismuth,  an  injection 
per  rectum  is  given  of  i  pint  (500  c.c.)  of  water  containing  30  grams 
(about  I  ounce)  of  bismuth  subcarbonate  or  barium  sulphate.  If  the 
stenosis  is  in  the  large  intestine  it  will  be  located  by  the  Rontgen  picture, 
there  being  the  area  apparently  free  from  bismuth  (the  stricture)  and  the 
collections  above  and  below  the  stricture. 

Location  of  the  Colon  by  the  X-rays. — Two  quarts  (liters)  of  water,. in 
which  60  grams  (about  2  ounces)  of  subnitrate  of  bismuth  or  bismuth 
subcarbonate  or  barium  sulphate  suspended  by  means  of  a  little  starch 
solution,  are  injected  per  rectum,  with  the  hips  elevated  or  in  the  knee- 
chest  posture.  The  position  of  the  colon  can  be  immediately  determined 
by  the  Rontgen  ray. 

One  could  administer  the  barium  by  mouth  and  examine  at  the  end 
of  twenty-four  hours,  but  the  enema  method  is  preferable.  Misplacements 
of  the  colon,  enteroptosis,  and  angulations  of  the  sigmoid  can  thus  be 
determined. 

It  has  been  claimed  that  a  soft  tube,  in  which  lies  a  flexible  wire,  can 
be  introduced  per  rectum,  and  the  course  of  the  colon  determined  by  the 
a;-rays,  the  wire  showing  a  shadow.  It  is  practically  impossible  to  insert 
the  tube  beyond  the  sigmoid,  so  the  method  is  not  accurate.  The  :«;-ray 
pictures  shown  of  the  long  colon-tube — supposedly  in  the  descending  colon 
— are  usually  in  the  ampulla  of  the  rectum.  H.  W.  Soper^  has  demon- 
strated, by  means  of  the  x-rays,  that  it  is  impossible  to  pass  the  colon- 
tube  into  the  sigmoid,  excep.t  in  the  case  of  Hirschsprung's  disease 
(congenital  idiopathic  dilatation  and  hypertrophy  of  the  colon). 

As  a  general  method  for  locating  the  position  of  the  colon  the  Rontgen 
rays  are  expensive  and  often  unnecessary  as  they  frequently  give  no 
more  information  than  by  inflation.  In  obscure  cases,  or  when  angula- 
tions, stricture,  adhesions  causing  stricture,  etc.,  are  suspected,  they  are 
of  value.     The  appendix  when  patent,  can  be  determined. 

Physiologic  Investigations  with  Rontgen  Rays. — Cannon's^  investigations 
have  already  been  described.  He  holds  that  some  of  the  material  after 
enema  may  be  forced  back  into  the  small  intestine,  and  that  this  may 
occur  with  a  high  nutrient  enema. 

Some  investigators  disagree  with  Cannon.  Grutzner  has  shown  that 
starch  granules,  lycopodium,  powdered  carbon,  etc.,  in  physiologic  salt 
solution,  injected  into  the  bowel  under  favorable  circumstances,  will 
find  their  way  upward  into  the  stomach. 

By  means  of  the  a;-rays  Hemmeter  observed  that  the  upward  move- 
ment of  these  particles  goes  on  simultaneously  with  the  downward  move- 
ment of  the  feces,  i.e.,  there  is  upward  marginal  current.  He  considers 
the  epithelia  and  muscularis  mucosa  as  instrumental,  and  that  it  is  not 
true  antiperistalsis. 

INFLATION  OF  THE  INTESTINES  WITH  CARBONIC  ACID  GAS  OR  AIR 

Von  Ziemssen^  first  employed  inflation  of  the  colon  for  diagnostic 
purposes  by  injecting  in  succession  into  the  bowel  solutions  of  tartaric 

'  Jour.  Amer.  Med.  Assoc,  Aug.  7,  igog. 
.  *  Amer.  Jour,  of  Physiol.,  vol.  vi,  p.  253. 
»  Deutsch.  Archiv  f.  klin.  Medizin,  1883,  Bd.  38,  S.  325. 
34 


530  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

acid  and  sodium  bicarbonate,  with  the  resulting  development  of  carbonic 
acid  gas.  The  bowel  could  then  be  recognized  by  the  marked  tympanitic 
sounds  on  percussion  or,  more  rarely,  by  inspection.  Preferably,  the  gut 
should  be  previously  emptied  by  enema. 

Inject  into  the  bowel  i  dram  (4.0)  of  tartaric  acid,  which  has  been 
dissolved  in  6  to  8  ounces  (200-250  c.c.)  of  water,  and  follow  it  by  the 
injection  of  the  same  quantity  of  soda  bicarbonate  in  same  amount  of 
water.     Preferably  the  hips  should  be  elevated. 

Schnetter  suggested  attaching  a  flexible  tube  with  rectal  tip  to  the 
nozzle  of  an  inverted  soda-water  siphon  and  driving  out  the  CO2  by 
pressing  the  valve. 

The  gas  has  also  been  injected  by  obtaining  it  from  the  liquefied  gas 
in  a  sparklet  and  conducting  the  CO2  from  a  bottle  into  the  rectum. 

One  of  the  simplest  methods  to  inflate  the  bowel  with  carbonic  acid  gas 
is  by  Rose's  gas  bottle.  This  consists  of  a  moderate-sized  bottle  with 
perforated  cork,  through  which  passes  a  glass  tube.  To  this  is  attached 
a  soft-rubber  tube  and  rectal  tip  (Fig.  256). 


Fig.   256. — Rose's  carbonic  acid  gas  generator. 

The  bottle  is  half-filled  with  water  and  i  dram  (4.0)  each  of  tartaric 
acid  and  soda  bicarbonate  added,  and  the  cork  tightly  inserted.  The 
accumulating  gas  is  conducted  off  by  the  tube  into  the  rectum.  Inspection 
and  percussion  will  determine  the  extent  of  distention. 

Runeberg^  recommended  inflation  of  the  intestines  by  air  by  means 
of  a  colon-tube,  to  which  a  compressible  air-bulb  is  attached.  It  is  possible 
by  this  means  to  measure  and  regulate  the  quantity  of  air  employed  for 
inflation. 

An  ordinary  Davidson's  syringe  can  be  used  to  pump  in  the  air,  and 
its  capacity  can  be  determined  as  follows: 

Take  a  measuring  glass  of  i  pint  (500  c.c.)  to  i  quart  (liter)  or  a  glass 
vessel  of  unknown  capacity  and  measure  its  capacity  when  filled  to  the 
brim.  Invert  the  filled  vessel  in  a  pail  of  water,  so  that  the  entire  column 
of  water  is  sustained  in  the  inverted  vessel.  Then  slip  the  colon-tube 
under  water,  so  that  its  tip  enters  the  inverted  glass.     Observe  how  many 

'  Deutsch.  Archiv  f.  Win.  Med.,  Bd.  34,  S.  460. 


TRANSILLUMINATION    OF    THE    INTESTINES  53 1 

compressions  of  the  bulb  are  required  to  replace  the  water  column  with 
air,  that  is,  to  drive  out  all  the  water  from  the  inverted  vessel. 

If,  for  example,  it  contained  i  pint  (500  c.c.)  of  water  and  it  required 
sixteen  squeezes  of  the  bulb  to  replace  this  by  air,  then  each  squeeze  of 
the  bulb  replaces  i  ounce  of  water  by  the  air  equivalent. 

Uses  of  Inflation. — It  is  of  service  to  detect  stenosis  of  the  large 
intestine.  Under  normal  conditions  the  injected  air  distends  the  colon 
evenly.  If  there  is  stenosis,  the  air  will  distend  chiefly  that  part  of  the 
bowel  below  the  stricture,  while  above  it  remains  unchanged.  This  is 
true  in  marked  strictures,  but  in  those  of  mild  type  the  air  will  pass 
through.  Even  in  some  such  cases  there  will  be  less  distention  above  than 
below  the  strictured  point. 

The  position  of  the  colon  can  be  determined  by  air  inflation.  Nor- 
mally it  passes  with  a  slight  downward  curve  across  the  abdomen  with 
lower  edge  about  touching  the  upper  margin  of  the  umbilicus,  or  it  may 
even  lie  just  below  or  above  the  latter. 

Enteroptosis  is  demonstrated  by  this  method,  and  the  transverse 
colon  may  descend  to  a  hand's  breadth  above  the  symphysis.  It  may  as- 
sume a  V  shape.  Angulations  of  the  sigmoid  may  at  times  be  determined 
by  this  means. 

For  the  diagnosis  of  the  location  of  abdominal  tumors,  inflation  of 
the  intestine  is  often  of  service.  After  inflation  of  the  colon  with  air, 
tumors  of  the  viscera  become  more  distinct;  while  tumors  of  the  kidney, 
retroperitoneal  glands,  spine,  etc.,  tend  to  disappear. 

Minkowski^  holds  that  after  filling  the  colon  with  air  or  water  ab- 
dominal tumors  are  shifted  in  the  direction  of  the  organ  to  which  they 
belong. 

Sutton^  suggests  inflating  the  bowel  with  air  impregnated  with  ether 
for  the  diagnosis  of  intestinal  perforation.  He  employs  a  bottle  provided 
with  a  perforated  rubber  cork  to  which  are  attached  two  rubber  tubes 
with  stop-cocks.  To  one  of  these  tubes  is  attached  a  bicycle  pump  or  a 
Davidson's  syringe;  to  the  other,  an  ordinary  colon-tube,  by  means  of  a 
short  glass  connecting  tube. 

Two  drams  of  ether  are  placed  in  the  bottle.  The  air  pumped  into 
the  bowel  passes  through  the  bottle  and  thus  takes  up  the  vapor  of  ether. 
With  the  stop-cocks  the  pressure  of  ether  and  air  can  be  regulated. 

If  perforation  of  the  bowel  is  present,  the  ether  escapes  through  the 
opening  into  the  abdominal  cavity  and  distends  it  equally  in  all  directions. 
If  there  is  no  perforation,  first  the  large  intestine  and  later  the  small  in- 
testine become  filled  with  air  and  ether,  and,  finally,  ether  vapor  may 
be  eructated  and  readily  recognized.  This  method  is  useful  in  gunshot 
wounds  of  the  abdomen. 

Inflation  of  the  Colon  with  Water. — This  can  be  performed  with  a 
graduated  irrigating  jar  and  a  rectal  tube.  With  a  fountain  syringe  of 
known  capacity  it  is  easy  to  estimate  the  quantity  injected. 

In  stricture  of  the  colon,  especially  in  the  lower  portion,  the  quantity 
of  water  which  can  be  injected  is  not  great.     Normally  the  colon  will 

^  Berlin,  klin.  Wochens.,  1888,  No.  31. 
*Jour.  Amer.  Med.  Asso«.,  Dec.  30,  1899. 


532  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

contain  from  3  to  4  quarts,  or  occasionally  5,  without  dangerous  disten- 
tion. The  injection  should  be  given  with  hips  elevated.  Many  people 
are  unable  to  hold  any  quantity  of  water  in  the  bowels  without  pain,  discomfort, 
and  rapid  evacuation  of  the  fluid. 

Determination  of  the  position  of  the  colon  by  inflating  it  with  water 
is,  therefore,  often  difficult.  The  air  inflation  is  preferable  for  the  above 
reasons. 

LAVAGE  OF  THE  BOWEL  FOR  DIAGNOSIS 

Boas^  first  recommended  this  procedure  to  be  carried  out  in  a  manner 
similar  to  lavage  of  the  stomach.  The  bowels  should  be  previously 
evacuated.  The  patient  should  lie  on  the  side  with  the  knees  and  thighs 
flexed.  The  colon-tube  is  attached  by  a  short  piece  of  metal  or  glass 
tubing  to  a  long  tube,  provided  with  a  funnel.  The  rectal  tube  is  lubri- 
cated and  inserted  high  up  to  its  full  length,  and  about  i  pint  (500  c.c.) 
to  I  quart  (liter)  gradually  poured  in  through  the  funnel  held  i  or  2  feet 
above  the  patient,  until  some  discomfort  is  expressed.  The  funnel  is 
then  lowered  below  the  anus  and  the  contents  siphoned  off. 

They  are  then  submitted  to  a  thorough  examination.  Normally 
the  contents  are  fairly  clear  or  slightly  stained  with  fecal  matter,  and 
contain  a  little  mucus  and  a  few  epithelial  cells. 

With  intestinal  catarrh  a  large  amount  of  mucus  is  present.  Blood 
or  pus  may  be  found,  showing  hemorrhages,  or  a  suppurative  process, 
such  as  an  ulcer  or  abscess.  Exfoliated  portions  of  the  mucous  membrane 
may  occasionally  be  found  or,  rarely,  tumor  fragments. 

Microscopic  examination  of  such  material  is  of  diagnostic  importance. 
Intestinal  worms  are  occasionally  discovered.  Lavage  of  the  bowel  is  also 
employed  for  the  removal  of  dysenteric  discharges  and  mucus,  and  for 
the  purpose  of  examination  for  amebge. 

EXAMINATION  OF  THE  FECES 

The  Stool. — General  Considerations. — The  normal  stool  consists  of 
changed  and  unchanged  remnants  of  food,  bacteria  (estimated  at  about 
126,000,000,000  daily),  epithelial  cells,  salts,  and  traces  of  the  digestive 
juices. 

The  normal  daily  quantity  under  a  mixed  diet  averages  100  to  even 
200  grams  {2>^i  to  7  ounces).  It  may  be  increased  by  a  vegetable  diet. 
There  is  usually  one  movement  daily  of  dark  brown  color,  though  diet 
and  medicine  have  an  influence.  Milk  gives  a  light  yellow;  claret  and 
huckleberries,  a  brownish  black;  salts  of  iron  and  magnesia,  a  blackish 
brown;  bismuth,  black.  Blue  is  given  by  iodids  (long  continued);  green 
by  calomel;  yellow,  by  santonin,  senna,  and  rhubarb;  violet,  by  salol  and 
betanaphtol.  The  feces  are  slightly  soft  and  of  sausage  shape.  Ab- 
normally they  may  appear  in  small  balls,  cylinders  or  tape-like,  or  as 
hard  scybalas  (dry  in  character,)  or  they  may  be  mushy  or  liquid.  They 
may  be  very  watery,  as  in  choleraic  conditions,  or  fluid  and  mixed  with 
mucus. 

^  Deutsch.  Aertze-Zeitung,  1895,  Nos.  2  and  3. 


EXAMINATION   OF   THE   FECES  533 

Odor. — This  is  normally  caused  by  skatol  and  slightly  by  indol.  It 
is  increased  when  the  feces  have  been  retained  an  abnormal  time.  After 
a  short  sojourn  in  the  intestines,  as  with  rice-water  movements,  there  is 
often  no  odor.  The  character  of  the  food  may  affect  the  odor.  Very 
fetid  movements  occur  with  ulcerative  processes,  or  with  malignant 
growths. 

Macroscopic  Findings. — Remnants  of  Food  in  the  Feces. — Undigested 
remnants  of  food  can  often  be  seen  in  the  stool.  Normally  they  consist 
of  only  small  particles  of  vegetable  material,  such  as  potato,  asparagus, 
spinach,  and  peas;  while  remnants  of  meat  cannot  be  seen.  Providing 
abnormal  quantities  of  food  have  not  been  ingested,  it  is  often  possible 
to  draw  definite  conclusions  as  to  the  state  of  intestinal  digestion,  from 
the  excess  of  one  form  of  non-digested  material  over  another.  The 
presence  of  large  quantities  of  undigested  starch  indicates  a  catarrhal  con- 
dition of  the  small  intestine,  and,  indeed,  more  than  traces  of  this  material 
should  be  regarded  with  suspicion.  If  particles  of  meat  are  visible,  this 
indicates  a  lesion  of  the  intestinal  tract.  Connective-tissue  fibers  appearing 
unaltered  in  the  feces  indicate  deficient  gastric  digestion,  according  to 
Schmidt,  and  the  presence  of  nuclei,  under  the  microscope,  disturbance 
of  the  trypsin  function  of  the  pancreas. 

Blood. — Blood  may  be  visible  in  the  feces,  either  fresh  (red)  or  dark 
in  color  and  uncoagulated,  which  shows  its  origin  from  the  lower  part 
of  the  large  bowel.  It  may  appear  changed,  giving  the  feces  the  appear- 
ance of  tar,  then  originating  from  the  small  intestine,  or  even  from  the 
stomach.  Blood  shows  the  presence  of  an  ulceration  or  of  an  ulcerating 
cavity  communicating  with  the  gut. 

Pus. — Visible  pus  in  the  dejecta  only  occurs  when  pus  exists  in  large 
quantities  in  the  lower  part  of  the  large  intestine.  It  shows  ulceration 
or  an  abscess  communicating  with  the  gut.  Pus  in  small  quantity  or 
from  higher  up  the  intestine  can  only  be  determined  by  the  microscope. 

Fragments  of  tumor  (polypi  or  cancer)  may  rarely  be  found  in  the 
dejecta.     Microscopic  examination  will  give  important  information. 

Mucus. — Mucin  can  always  be  detected  in  normal  feces  by  chemic 
examination.  The  amount  of  mucus  in  the  feces  in  health  is  so  small 
and  so  intimately  mixed  as  to  be  only  recognized  by  chemic  tests.  Mucus 
in  the  stool,  either  macroscopic  or  microscopic,  indicates  some  deviation 
from  the  normal  physiologic  condition.  It  does  not  invariably  show  an 
anatomic  lesion.  We  may,  for  example,  have  a  few  flakes  of  mucus  or  an 
extremely  thin  layer  adherent  to  scybalse,  due  to  irritation  of  the  mucosa 
from  a  fecal  accumulation  or  impaction,  or  mucus,  which  is  contained 
normally  in  the  higher  portions  of  the  small  intestine,  may  occasionally 
appear  in  the  stool  as  a  result  of  increased  peristalsis. 

Under  other  circumstances  the  presence  of  mucus  is  pathologic. 
Macroscopically,  mucus  may  exist  as  follows: 

(i)  An  abundant  coating  in  the  form  of  a  glassy  layer  may  cover  fecal 
masses.  It  may  be  gray  or  cloudy  from  epithelial  or  round  cells.  This 
usually  indicates  catarrh  of  the  lower  portion  of  the  bowel. 

(2)  It  may  be  intimately  mixed  with  the  feces  in  mushy  movements, 
and  may  adhere  to  a  glass  rod  if  this  is  dipped  in  the  stool. 


534  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

(3)  It  may  float  on  top  of  watery  movements. 

(4)  It  may  be  passed  almost  pure  in  large  amount. 

Material  resembling /rog'5  spawn  or  sago  grains  may  occur  in  the  feces. 
They  were  formerly  considered  due  to  follicular  ulceration,  but  are  now 
believed  to  be  of  vegetable  origin.  Kitagawa  holds  that  some  of  them 
are  pure  mucus,  but  that  they  are  not  pathologic. 

Yellow  or  yellowish-brown  granules  occur  in  the  stool,  from  the  size 
of  a  pinhead  to  a  poppy  seed,  resembling  butter  in  consistency.  Some 
of  these  have  been  considered  bile-stained  mucus,  while  other  fragments 
are  believed  to  be  albuminous,  or  vegetable  material,  or  yellow  calcium 
salts. 

Boas  and  Schmidt  believe  these  yellow  granules  to  be  albuminous 
matters  stained  with  bile-pigment. 

The  presence  of  any  one  of  the  previously  described  types  of  mucus 
indicates  intestinal  catarrh.  Mucus  without  feces,  or  surrounding  the 
feces,  shows  the  colon  is  inflamed.  When  mucus  is  mixed  with  the  feces 
the  upper  colon  or  small  intestine  is  inflamed.  Mucus  in  the  food  residue 
shows  catarrh  of  the  small  intestine. 

There  are  two  exceptions  to  the  rule  that  visible  mucus  indicates 
catarrh. 

(i)  In  mucous  coUc  (membranous  enteritis)  pure  mucus  due  to  hyper- 
secretion is  evacuated  in  the  form  of  a  cast  membrane  or  in  long  tape-like 
formation. 

(2)  In  intestinal  dyspepsia  with  acid  fermentation  the  patient  has 
a  jejunal  diarrhea,  with  gelatinous,  tenacious,  semifluid  stools.  Mucus 
is  present. 

Epithelial  or  round  cells,  which  are  abundant  in  catarrhal  mucus,  are 
absent  from  the  mucus  in  dyspepsia  of  the  small  intestine.  The  stools 
are  also  green,  acid,  and  give  a  bile-pigment  reaction. 

Intestinal  parasites  may  be  visible  in  the  feces. 

Chemic  Examination  of  the  Feces. — Reaction  is  normally  neutral  or 
slightly  alkaline.  Marked  acidity  results  from  occlusion  of  the  bile-duct. 
Rich  vegetable  diet  causes  slight  acidity.  The  simplest  method  to  test 
the  reaction  is  by  litmus-paper  (red  and  blue). 

Normal  stools  react  slightly  differently  with  different  indicators. 
With  phenolphthalein  they  react  slightly  acid,  while  to  litmus  they  would 
be  neutral.  If  the  phenolphthalein  test  is  employed,  take  feces  5.0 
c.c,  rub  up  in  a  mortar,  and  add  30.0  c.c.  distilled  water,  after  the  modified 
Schmidt  diet.  Place  2  c.c.  of  this  in  a  test-tube,  add  2  drops  of  i  per 
cent,  alcoholic  solution  of  phenolphthalein.  With  this  quantity  titration 
with  decinormal  sodium  hydrate  never  exceeds  1.5  c.c.  to  secure  end-re- 
action. Above  this  the  stool  should  be  considered  acid,  and  if  less  than 
I  c.c.  it  may  be  considered  alkaline  (Kaplan^). 

For  general  use  the  litmus  test  is  sufficient. 

Test  for  Mucin. — Mucin  is  normally  present  in  the  feces.  Mix  feces 
with  water  and  an  equal  quantity  of  milk  of  lime  and  let  the  mixture  stand 
for  several  hours.  Then  filter,  add  acetic  acid  to  filtrate,  and  mucin 
precipitates  if  present. 

^  N.  Y.   Med.  Jour.,  Dec.   7,   1907. 


EXAMINATION   OF   THE    FECES  535 

To  Examine  Separate  Particles  of  Suspected  Mucus. — Dissolve  a  flake 
of  material  in  a  weak  solution  of  potassium  or  sodium  hydroxid  and  add 
acetic  acid.  If  the  precipitate  is  undissolved  after  adding  the  acid  in 
excess,  mucin  is  present.  Heat  the  precipitate  to  the  boiling-point  in  a 
dilute  mineral  acid;  if  mucin  is  present  the  heated  solution  will  reduce 
copper  oxid.  This  last  test  excludes  nucleo-albumin,  which  otherwise 
gives  a  similar  reaction  (Einhorn).  Stain  a  flake  of  apparent  mucus  with 
a  weak  triacid  solution  (Ehrlich),  mucus  produces  a  green  color;  albumin, 
red.  This  test  is  of  value  in  determining  the  presence  of  mucus  in  mem- 
branous specimens  from  mucous  colic.  The  tests  otherwise  are  rarely 
required. 

Albumin. — Treat  the  feces  with  water  slightly  acidified  with  acetic 
acid.  Filter  the  watery  extract  and  employ  boiling  test  as  for  albumin  in 
the  urine.  Normally,  no  albumin  is  present,  but  it  has  been  found  in 
typhoid,  occasionally  in  acute  enteritis,  and  in  chlorosis. 

Propeptone  and  Peptone. — After  the  test  for  albumin  has  proved  nega- 
tive, the  watery  extract  of  the  feces  is  treated  with  phosphotungstic  acid, 
the  precipitate  is  diluted  with  water  and  sodium  hydrate,,  and  a  small 
amount  of  a  weak  solution  of  sulphate  of  copper  added.  A  purple  red 
(biuret  reaction)  shows  the  presence  of  both  propeptones  and  peptones. 
To  determine  the  presence  of  peptones  separately,  first  precipitate  the 
propeptones  by  ammonium  sulphate  in  large  amount. 

Pathologically,  peptone  is  found  in  typhoid,  dysentery,  tuberculous 
ulcer  of  the  intestine,  and  in  perforative  peritonitis.  Normally  it  is  not 
present. 

Carbohydrates. — The  feces  are  first  subjected  to  distillation.  The 
residue  is  extracted  with  alcohol  and  ether;  the  extract  boiled  with  water, 
filtered,  and  again  boiled,  with  the  addition  of  dilute  sulphuric  acid. 
Trommer's  or  Nylander's  test  is  then  employed. 

Examination  for  Starch. — The  watery  extract  of  feces  is  examined  with 
Lugol's  solution,  the  presence  of  starch  producing  a  blue  color. 

For  Sugar. — ^A  watery  extract  of  feces  can  be  directly  tested  by 
Fehling's  method. 

Normally,  neither  starch  nor  sugar  are  found. 

Gas  Fermentation. — Schmidt's  method  will  be  described  later. 

Fat. — The  feces  are  treated  with  considerable  ether,  and  the  latter  is 
separated  and  evaporated  in  a  water-bath.  The  neutral  fat,  if  present, 
remains  visible. 

To  show  the  presence  of  soaps  which  do  not  dissolve  in  ether,  another 
portion  of  fecal  matter  is  first  treated  with  acids  which  split  up  the  soaps, 
and  then  extracted  with  ether;  quantitative  determination  is  complicated. 

Normally,  fat  is  never  present  macroscopically  in  the  stools  unless 
after  ingestion  of  very  large  quantities.  It  may  then  be  visible  in  very 
small  portions,  the  size  of  a  pea.  Pathologically,  fat  may  exist  in  large 
quantities  in  the  fecal  matter  and  give  the  grayish-silver  fatty  stools, 
especially  in  disease  of  the  pancreas  and  whenever  lymphatic  absorption 
is  disturbed. 

Blood. — Fresh  blood  can  often  be  recognized  macroscopically.  The 
tests  for  occult  (concealed)  blood  are  of  importance.     The  best  methods 


536  DISEASES    OF   THE    STOMACH    AND    INTESTINES 

are  the  benzidin  test  (the  latest);  Weber's  modification  of  the  guaiac  test; 
and  the  aloin  test.  These  are  fully  described  under  Tests  for  Occult 
Blood  in  the  Stomach-contents  and  Stools  in  Part  II  of  this  volume. 
Neither  meat  nor  iron  preparations  should  be  ingested  for  two  or  three 
days  previous  to  the  tests.  The  hemin  test  has  been  employed.  A 
small  particle  of  fecal  material  is  dried,  powdered,  and  placed  on  a  slide. 
A  trace  of  sodium  chlorid  is  added  and  a  drop  of  glacial  acetic  acid  poured 
on  and  thoroughly  mixed.  A  cover-glass  is  placed  over  the  specimen  and 
the  slide  slowly  heated.  After  cooling,  a  m.icroscopic  examination  is  made. 
In  the  presence  of  blood,  hematin  crystals  are 
found   (Fig.    257).     These   are  reddish  pink  and 

^    A    ^      -^  rhomboid  in  shape. 

^w  w     ^^  Bile-pigment. — Normally,    no  unchanged   bile- 

^r X  \  ^.^  pigment  is  found  in  the  feces.     In  catarrh  of  the 

^         I  ^^  ^^     small  intestine  it  has  been  detected.     The  presence 

\|      ^L    ^     of  bile-pigment  is  determined  as  follows:    A  par- 
^^-—         tide  of  the  colored  fecal  matter  is  brought  into 


contact  with  a  drop  of  fuming  nitric  acid-.     The 

Fig   257  —Hematin       yellow  color  passes  through  the  various  colors  of  the 

crystals.  spectrum,  red,  violet,  to  green ;  in  some  cases  green 

appears   at   once;   or  liquid  feces  can  be  filtered 

through  filter-paper  or  a  watery  mixture  can  be  made  and  then  filtered. 

The  paper  is  then  dried  and  a  drop  or  two  of  the  fuming  nitric  acid 

poured  on  it.     The  colors  will  appear  in  rings  if  bile  is  present;  or: 

A  small  quantity  of  the  feces  is  treated  with  a  concentrated  watery 
solution  of  corrosive  sublimate.  Biliary  pigments  will  turn  the  mixture 
green,  or  green  appears  in  that  portion  where  pigments  are  present. 

Biliary  Acids. — These  usually  accompany  biliary  pigments.  They 
are  revealed  by  Pettenkofer's  test:  A  small  quantity  of  feces  is  treated 
with  alcohol  and  then  the  latter  is  evaporated.  To  the  residue  a  weak 
watery  solution  of  bicarbonate  of  soda  is  added,  and  to  this  mixture  a 
small  amount  of  cane-sugar  and  a  few  drops  of  sulphuric  acid.  Red  or 
pink  occurs  when  biliary  acids  are  present. 

Urobilin. — Normally,  the  biliary  pigment  in  the  intestinal  tract  be- 
comes changed  to  stercobilin,  which  gives  the  brown  color  to  the  feces. 

A  small  piece  of  fecal  matter  is  treated  with  a  concentrated  watery 
solution  of  corrosive  sublimate  and  thoroughly  mixed  with  a  glass  rod. 
Urobilin  (stercobilin  )  gives  rise  to  a  pinkish-red  color;  bilirubin,  to  a 
green  color.  Urobilin  is  normally  present  and  is  absent  in  pathologic 
conditions,  while  bilirubin  is  present  in  the  latter. 

Fleischer's  Test. — Place  a  small  quantity  of  feces  in  a  test-tube  with 
a  small  amount  of  alcohol  to  which  has  been  added  a  few  drops  of  hydro- 
chloric or  acetic  acid.  After  a  short  time  urobilin  produces  a  yellow  or 
brown  color.  If  the  alcohol  is  then  poured  off  and  a  few  drops  of  sodium 
hydroxid  with  a  small  quantity  of  zinc  chlorid  are  added,  there  appears 
a  green  fluorescence  in  direct  rays  of  light,  and  in  transmitted  light,  pink 
or  yellowish  red,  greater  or  less  in  proportion. 

Acholic  and  Colorless  Stools. — The  acholic  stool  presents  a  grayish 
white,  ash-gray,  or  clay  color  due  to  absence  of  bile-pigment.     The  de- 


EXAMINATION   OF   THE   FECES 


537 


jecta  are  of  penetrating  odor,  buttery  consistency,  and  on  chemic  and 
microscopic  examination  are  found  to  contain  much  fat.  The  latter 
is  present  as  needle-shaped  crystals,  or  in  sheaves  of  crystals,  or,  less 
generally,  in  fat-droplets.  This  type  of  stool  occurs  in  conditions  such 
as  occlusion  of  the  bile-duct,  when  there  is  an  exclusion  of  bile  from  the 
intestine. 

Stools  can  be  entirely  devoid  of  color  or  of  a  grayish-white  color  re- 
sembling true  acholic  stools,  though  there  is  no  jaundice  or  occlusion  of 
the  bile-ducts.  These  stools  are  less  putrid  in  odor  and  more  acid.  They 
contain  enormous  amounts  of  fat,  like  the  true  acoholic  stool,  and  urobilin 
has  been  demonstrated  in  them.  Such  movements  occur  in  conditions  when 
the  absorption  of  fat  is  impaired,  as  in  tuberculosis  of  the  intestines  and 
peritoneum.  At  other  times  abnormal  quantities  of  fat  are  not  present, 
and  the  lack  of  color  is  imputed  to  the  presence  of  a  colorless  decomposition 
product  of  bilirubin,  the  leuko-urobilin  of  Mencki. 

The  conclusion  that  a  stool  contains  an  excessive  amount  of  fat  be- 
cause it  is  apparently  acholic,  is  not  justifiable  unless  a  microscopic  ex- 
amination is  made.  An  apparently  acholic  stool  may  also  be  due  to 
excessive  fat  ingestion  and  urobilin  be  present. 

Fatty  Stools  (Steatorrhea). — This  term  is  applied  to  all  cases  in  which 
isolated  masses  of  fat  are  present  in  the  feces  and  can  be  recognized  with 
the  naked  eye.  It  appears  in  whitish  or  grayish  lumps,  or  it  may  cling 
around  the  feces  or  be  adherent  to  the  vessel. 

Ingestion  of  excessive  fat  even  under  normal  conditions  may  produce 
an  evacuation  of  superfluous  fat.  If  the  mucosa  of  the  small  intestine 
and  the  lymphatic  system  (mesenteric  glands)  lose  their  powers  of  ab- 
sorption, fat  must  appear  in  the  stools,  as  in  tuberculosis  of  the  small 
intestine,  chronic  tubercular  peritonitis,  intestinal  catarrh,  etc. 

In  occlusion  of  bile  from  the  intestines  with  acholic  stools,  the  fat  is 
revealed  microscopically  and  by  chemic  analysis,  but  fatty  stools  are  not 
then  spoken  of  in  the  clinical  sense. 

Steatorrhea  is  not  per  se  diagnostic  of  pancreatic  disease.  In  the 
absence  of  icterus  and  of  demonstrable  intestinal  disease,  fatty  stool 
is  probably  due  to  pancreatic  disease.  Disturbed  digestion  of  fat  is 
diagnostic  of  pancreatic  disease.  Muller  shows  that  qualitative  changes 
in  the  fat  (lipolysis)  is  much  slighter,  only  39.8  per  cent,  in  pancreatic 
disease,  where  it  is  84  per  cent,  in  healthy  subjects,  or  even  in  those  with 
icterus,  if  the  pancreatic  juice  has  free  access. 

Ferments. — A  glycerin  extract  can  be  made  of  the  feces,  or  the  fecal 
matter  may  be  mixed  with  water  containing  a  small  proportion  of  thymol 
and  filtered. 

To  test  for  trypsin,  the  filtration  extract  is  made  alkaline  by  the  ad- 
dition of  soda  bicarbonate  and  a  few  flakes  of  fibrin  added.  The  solutions 
are  kept  at  a  blood  temperature  for  a  few  hours  and  then  tested  with 
potassium  hydroxid  and  a  weak  solution  of  copper  sulphate.  If  trypsin 
is  present,  there  will  be  a  pinkish-red  reaction  (biuret)  in  consequence  of 
peptone. 

For  Diastase. — A  few  cubic  centimeters  of  the  filtrate  are  mixed  with 
about  one-half  the  amount  of  a  starch  solution  and  kept  at  a  blood  tern- 


538  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

perature  for  about  thirty  minutes.  The  mixture  is  then  subjected  to 
FehUng's  or  Trommer's  test.  Normally,  these  ferments  are  absent,* 
but  in  pathologic  conditions,  especially  in  diarrhea,  they  are  frequently 
found.  Wynhausen^  describes  a  new  test  for  the  pancreatic  activity. 
(See  Testing  the  Pancreatic  Functions.) 


Fig.   258. — Einhorn's  stool  sieve. 

Concretions,  Foreign  Bodies,  Worms. — To  examine  for  such  material 
the  feces  should  be  thoroughly  mixed  with  water  and  poured  through  a 
sieve.  This  can  be  improvised — a  circular  wire  rim  can  be  fitted  to  a 
water-closet  seat,  and  attached  to  the  wire  a  network  bag  made  of  two 
thicknesses  of  cheese-cloth,  practically  a  dip-net.  The  patient  defecates 
in  the  net,  and  water  can  then  be  poured  through  several  times  until 
only  the  more  solid  parts  remain. 

Boas  has  constructed  a  stool  sieve,  and  Einhorn's,  as  in  Fig.  258,  is 
readily  understood.  Water  is  poured  through  and  there  is  a  stirring 
apparatus. 

Concretions. — Among  such  are  gall-stones,  pancreatic  calculi,  entero- 
liths, and  coproliths.  Biliary  calculi  are  readily  recognized  when  of  any 
size.  The  principal  constituents  are  cholesterin,  bile-pigment,  and 
lime. 

Tests  for  small  biliary  concretions  (sand)  are  as  follows:  first,  powder 
30  grains  (2.0)  of  the  mass  and  treat  with  ether,  5  drams  (20  c.c),  mix  and 
filter,  evaporate,  and  test  for  cholesterin.  Dissolve  part  of  residue  in 
hot  alcohol  and  allow  it  to  evaporate.  Microscopic  examination  of  the 
precipitate  shows  rhomboid  crystals  with  ragged  edge  (cholesterin); 
second,  another  part  of  the  residue  is  placed  on  a  slide,  a  drop  of  concen- 
trated sulphuric  acid  added  and  covered  with  a  cover-glass,  the  cholesterin 
crystals  become  carmine  at  their  edges,  add  i  drop  of  Lugol's  solution  and 
a  violet  color  arises;  finally,  a  portion  of  the  residue  is  treated  with  hydro- 

^  Goldschmidt  (Deut.  med.  Wochens.,  1909,  No.  12,  xxv,  522)  and  Gross  (Ibid., 
1909,  No.  16,  xxv,  706),  using  the  latter's  method  for  detecting  trypsin,  have  discovered 
it  in  the  feces  of  all  normal  persons  examined.  This,  if  confirmed,  will  prove  a  great 
advance. 

-  Berl.  klin.  Wochens.,  July  26,  1909;  also  Med.  Rec,  Sept.  11,  1909. 


EXAMINATION    OF    THE    FECES  539 

chloric  acid,  a  trace  of  iron  chlorid,  and  then  evaporated.     If  cholesterin 
is  present,  a  blue  color  occurs. 

The  residue  of  the  original  ether  mixture  is  treated  with  dilute  hydro- 
chloric acid  mixture,  heated,  and  extracted  with  chloroform  after  cooling. 
The  chloroform  extract  is  tested  with  Gmelin's  reaction  (fuming  nitric 
acid).     Bile-pigment  produces  the  rainbow  play  of  colors. 

Pancreatic  Calculi. — These  usually  have  a  rough  surface,  are  brittle, 
and  may  be  faceted.  They  are  soluble  in  chloroform,  and  on  evapora- 
tion produce  an  aromatic  odor.^  Bile-pigment  and  cholesterin  are 
usually  absent.     (See  Pancreatic  Lithiasis.) 

Enteroliths. — Calculi  formed  in  the  small  intestine  consist  of  inorganic 
salts  (lime  and  magnesia).  They  are  light  in  color  and  usually  of  small 
size.  They  form  occasionally  after  the  extensive  use  of  lime  and  magnesia. 
Rarely  they  cause  obstruction. 

Coproliths  {fecal  calculi)  are  found  in  the  large  bowel,  chiefly  where 
there  is  retardation  to  the  passage  of  feces,  as  in  the  cecum,  appendix, 
sacculi  of  the  colon,  sigmoid,  and  rectum.  They  are  of  stony  hardness 
and  sausage  shape  and  show  concentric  rings  on  section.  They  may 
attain  considerable  size  and  even  cause  intestinal  obstruction. 

Foreign  Bodies. — Bodies  which  have  been  swallowed  may  pass  through 
the  entire  bowel  and  be  passed  in  the  feces,  such  as  bones,  coins,  marbles, 
oyster  shell  fragments,  needles,  etc.  Concretions  of  shellac  have  been 
found  in  the  stools  of  patients  who  have  drunk  furniture  polish.  Hair- 
balls  may  be  found. 

Microscopic  Examination. — The  microscopic  examination  of  the  feces 
is  often  of  great  assistance  to  diagnosis.  For  examination  for  amebae 
the  stool  should  be  kept  warm.     A  thermos  bottle  is  useful  for  this  purpose. 

To  diminish  the  disagreeable  odor  of  a  watery  stool,  place  it  in  a 
conic  glass  and  cover  it  with  a  layer  of  ether.  If  it  is  mushy  or  firm, 
it  can  be  spread  on  a  plate  and  covered  with  a  layer  of  spirits  of  turpen- 
tine, or  a  5  per  cent,  solution  of  carbolic  acid  or  thymol,  or  4  per  cent, 
formalin. 

Diarrheal  stools  may  be  examined  without  further  preparation. 

With  solid  fecal  matter,  a  small  piece  of  feces  may  be  placed  on  a 
slide  and  mixed  with  a  drop  or  two  of  normal  salt  solution.  If  there 
is  odor,  a  i  per  cent,  formalin  solution  may  be  added.  The  findings 
depend  on  the  diet.  With  meat  diet,  no  vegetable  residue  is  found, 
and  vice  versa.  With  a  mixed  diet,  in  a  normal  stool,  there  will  be 
plant  cells,  the  remnants  of  various  vegetables  and  fruits,  no  starch 
granules,  meat-fibers  changed  beyond  recognition,  or  with  slight  stria- 
tion  (Fig.  259).  More  commonly  they  appear  as  oval  yellow  translucent 
masses  with  a  high  degree  of  refractibility.  The  presence  of  numerous 
meat-fibers  striated  and  with  nuclei  is  pathologic,  showing  deficient 
pancreatic  digestion  (tryptic).     They  may  appear  as  spirals  (Fig.  260). 

Fat. — Fat  appears  microscopically  as  colorless  small  globules  or  as 
needle-shaped  crystals  (fatty  acids)  or  in  sheaves  (soaps).     The  fatty 
acids  disappear  when  heated  or  when  ether  is  added;  soaps  remain  un- 
changed.    Sudan  dye-stuff,  in  concentrated  alcoholic  solution,  stains  plain 
»Minch,  Berl.  klin.  Wochens.,  1898,  No.  8. 


540 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


fat  bright  red,  while  crystals  of  fatty  acid  and  the  soaps  remain  unchanged. 
In  pathologic  conditions  these  forms  of  fat  are  markedly  increased,  as  in 
affections  of  the  liver,  pancreas,  and  intestines.  Normally,  they  are 
scanty. 


Fig.  259. — General  view  of  the  feces:  a,  Epithelial  cells  and  leukocytes;  b,  stone- 
cells;  c,  cuticular  formations;  d,  crystals  of  ammoniomagnesium  phosphate;  e,  fat- 
crystals;  /,  yeast-fungi;  g,  Amoeba  coli;  h,  Trichomonas  intestinalis;  i,  Cercomonas 
intestinalis;  m,  ovum  of  ascaris;  n,  ovum  of  oxyuris;  0,  ovum  of  trichocephalus;  p, 
ovum  of  ankylostomum;  q,  ovum  of  bothriocephalus;  r,  ovum  of  Taenia  saginata;  s, 
ovum  of  Taenia  sodium  (Jakob). 

Crystals. — Oxalate  of  lime,  calcium  carbonate,  neutral  phosphate 
of  calcium,  and  ammonium  magnesium  phosphate  are  found  in  normal 
as  well  as.  pathologic  feces  and  have  no  diagnostic  importance.  Bis- 
muth, if  administered,  occurs  as  dark  brown  or  nearly  black  rhomboid 


Fig.  260. — a.  Spirals  of  undigested  meat-fibers  in  stool;  b,  pieces  of  bronchi. 

(Butler). 

crystals.  Hematoidin  appears  in  rhombic  crystals  of  orange  or  red 
color,  shortly  after  intestinal  hemorrhage.  Charcot-Leyden  crystals 
(Fig.  261)  are  fine  colorless,  pointed  octahedra.  These  when  present 
ezdte  the  suspicion  of  helminthiasis   (intestinal  parasites),  and  their 


EXAMINATION   OF   THE   FECES 


541 


persistence  after  removal  of  the  tenia  shows  the  head  has  probably  not 
been  removed.  They  occur  occasionally  in  normal  stools  and  in  typhoid, 
dysentery,  and  phthisis. 

Epithelium. — Epithelial  cells  when  present  in  large  numbers  always 
indicate  an  inflammatory  condition  of  some  part  of  the  intestinal  tract. 
Cylindric  epithelial  cells  are  found  in  abundance  in  inflammation  of  the 
intestinal  mucosa  (Fig.  262).  They  cause  the  cloudy  appearance  of  the 
mucus.  If  bile-stained  specimens  of  epithelia  are  met  with,  the  small 
intestine  is  involved.  Degenerative  forms  without  nuclei  are  mostly  seen, 
though  well-preserved  cylindric  or  goblet-cells  are  often  found. 

Red  blood  cells  are  rarely  observed  unless  hemorrhage  is  from  the 
colon  or  rectum,  as  in  dysentery.  Hemorrhage  higher  up  gives  a  brownish- 
red  color  to  the  feces,  and  hematoidin  rhombic  crystals  in  some  cases,  and 
the  blood  cells  cannot  be  recognized  microscopically. 


Fig.  261. — Charcot-Leyden  crystals  (after  Riegel). 


Pus  occurs  in  the  dejecta  in  ulcerative  processes  when  an  abscess 
communicates  with  the  bowel,  or  in  dysentery,  or  in  any  form  of  intestinal 
ulcer.  It  presents  the  usual  characteristics.  Often  it  can  only  be  deter- 
mined by  the  microscope. 

Mucus  when  bile-stained  indicates  disease  of  the  small  intestine; 
and  if  colorless,  catarrh  of  the  large  intestine  or  lower  part  of  small  in- 
testine is  present.  Mucus  also  occurs  with  mucous  colic,  in  which 
condition  no  catarrh  exists.  Mucus  is  thread-like  in  appearance,  though 
occasionally  amorphous  (Fig.  263).  Hyaline  particles  of  vegetable 
residue  must  not  be  mistaken  for  mucus.  lodin  stains  it  blue.  Thionin 
colors  it  reddish  violet  and  other  proteins  blue.  Mucus  has  no  definite 
structure. 

Tumor. — Fragments  of  tumor  may  rarely  be  found  in  the  feces  and 
its  character  determined  by  the  microscope. 


542 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Microorganisms. — A  large  portion  of  the  stool  is  constituted  by 
bacteria,  as  already  mentioned.  Among  the  most  important  are  the 
Bacillus  coli,  Bacillus  lactis  aerogenes,  Bacillus  bifidus,  Bacillus  aerogenes 
capsulatus  (gas-forming),  and  Bacillus  putrificus. 

The  Bacillus  coli  is  of  importance  in  reference  to  the  indolic  type, 
and  the  Bacillus  aerogenes  capsulatus,  to  the  saccharobutyric  type  of 
intestinal  putrefaction.  The  Bacillus-lactis  aerogenes  causes  fermentation 
of  milk  and  the  production  of  lactic  acid. 

The  lactic-acid-producing  bacilli  are  held  to  be  antagonistic  to  put- 
refactive changes.  For  a  description  the  reader  is  referred  to  any  work  on 
Bacteriology.  Typhoid,'  tubercle,  dysenteric,  and  the  cholera  bacilli 
are  the  chief  pathogenic  microorganisms  found  in  the  feces  which  are  of 
interest  to  us. 


Fig.  262. —  Chronic  intestinal  catarrh:  Fig.  263. — Intestinal     catarrh:     Con- 
Groups  of  epithelial  cells,  detritus,  some  siderable   mucus,   some  plant  cells,   mus- 
muscle    cells    partly    digested,    bacteria,  cle  cells,  and  fat  crystals, 
plant  cells,  and  yeast  cells. 


Preparation  of  Feces  for  Examination  for  Parasitic  Ova. — Mix  a 

small  amount  of  the  feces,  a  portion  3^  inch  in  diameter,  with  10  to  15 
c.c.  of  equal  parts  of  25  per  cent,  antiformin  and  ether  and  shake  thor- 
oughly. When  the  feces  are  hard,  they  may  first  be  warmed  with  the 
antiformin  and  the  ether  subsequently  added.  After  shaking,  filter  the 
mixture  through  gauze  and  centrifugalize  the  filtrate.  Four  layers  are 
thus  obtained.  The  upper  consists  of  the  ether  holding  in  solution,  the 
neutral  fats  and  fatty  acids.  The  next  layer  is  a  ring  made  up  of  coarse 
vegetable  fibers,  etc.  The  third  layer  is  the  antiformin  containing  soaps, 
soluble  mucus  and  coloring  matter,  and  the  lower  layer  consists  of  the 
remaining  sediment  of  the  feces.  It  may  contain  cellulose,  epitheUa, 
salts,  elastic  fibers  and  muscle  fibers.  It  is  in  this  material  that  the  para- 
sitic ova  may  be  found.  The  sediment  is  transferred  to  a  glass  slide  and 
searched  in  the  usual  way.  The  ova  will  be  found  to  be  a  little  or  not  at 
all  influenced  by  the  reagent;  50  per  cent,  antiformin  is  slightly  de- 
structive toward  the  ova. 


TESTING    THE    INTESTINAL    FUNCTIONS 


543 


TESTING  THE  INTESTINAL  FUNCTIONS 

(E.  E.  Smith,  M.  D.) 

Boas  has  obtained  intestinal  juice  by  passing  the  stomach-tube 
into  the  empty  organ  and  massaging  the  region  of  the  liver,  thus  forcing 
the  juice  into  the  stomach.  Hemmeter  and  Kuhn  have  passed  the  tube 
directly.     These  procedures  are  uncertain  and  possess  no  advantages. 

Einhorn^  has  devised  a  new  method  of  obtaining  the  intestinal  juice 
by  means  of  a  duodenal  bucket.  The  quantity  secured  (and  it  is  not 
always  obtained)  is  infinitesimally  small;  there  is  the  possibility  of  an 
admixture  of  gastric  juice  and  saliva  during  withdrawal,  and  the  procedure 
requires  three  to  five  hours  or  even  longer.  It  does  not  admit  of  the 
thorough  technic  as  secured  by  Schmidt's  test-diet. 

Einhorn  has  recently  suggested  passing  a  soft  tube  along  the  duodenal 
bucket  cord  (on  the  principle  of  Gouley's  tunnel  sound  along  the  filiform 
bougie),  and  then  aspirating  the  intestinal  contents  with  a  bulb. 

Einhorn's  bead  test^  the  author  does  not  believe  to  be  sufficiently 
accurate.  Testing  the  motor  function  with  foreign  bodies  (beads) 
is  not  a  proper  criterion;  the  food  material  attached  to  each  bead  is 
too  infinitesimally  small  in  amount  to  test  the  digestive  capacity  for  an 
average  diet;  it  may  work  loose  from  the  beads,  in  which  event  it  could 
not  be  recovered  and  wrong  deductions  might  result.  There  is  a  slight 
element  of  risk  from  fish-bone  escaping  from  the  bead  and  damaging  the 
mucosa.  Additional  methods  of  securing  the  secretion  of  the  pancreas, 
such  as  by  means  of  the  duodenal  tube,  etc.,  are  described  under  Diseases 
of  the  Pancreas. 

The  author  believes  the  stomach  Junctions  should  he  tested  separately, 
and  one  should  not  depend  on  the  connective-tissue  test  for  the  stomach 
test  also,  as  suggested  by  Schmidt. 

Boldyreff's  oil  test-meal,  the  tests  of  Mett,  Volhard,  and  Gross,  and 
the  duodenal  pumps  of  Gross  and  Einhorn  are  described  under  Diseases 
of  the  Pancreas. 

Tests  of  the  Intestinal  Functions. — The  determination  of  the  func- 
tional activity  of  the  stomach  is  made  with  relative  ease,  compared 
to  the  similar  examination  of  the  intestines.  Correspondingly,  methods 
for  such  determination  have  long  been  applied  to  the  former  organ,  while 
they  have  recently  found  application  to^the  latter;  and  even-  now  the 
diagnostic  determination  of  intestinal  function  by  exact  methods  is  only 
in  its  infancy.     The  problems  presented  are  essentially  these: 

(a)  Is  intestinal  secretion,  including  pancreatic  and  biliary  secretions, 
normal  in  quality  and  quantity?  {h)  Is  intestinal  absorption  normal? 
(c)  Is  the  intestinal  motor  activity  normal?  If  not,  in  what  respect  is 
each  of  these  processes  abnormal? 

The  investigation  of  these  problems  is  made  by  the  use  of  a  test- 
diet.  While  in  the  case  of  the  stomach,  the  diet  is  relatively  simple 
and   the  digestive  mixture  withdrawn  for  examination   within   a   few 

^N.  Y.  Med.  Jour.,  June  20,  1908. 

*Med.  Rec,  Feb.  10,  1906;  Ibid..  Oct.  26,  1907;  Jour.  Amer.  Med.  Assoc  ,  Feb.  2, 
1907;  Therapeutic  Gaz.,  Jan.  15,  1908. 


544  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

hours,  in  the  case  of  the  intestines,  only  inferences  as  to  the  intestinal 
contents  may  be  reached,  and  then  indirectly  from  the  conditions  affect- 
ing the  bowel  contents  after  they  have  been  ejected,  perhaps  in  one  or 
several  days.  The  feces  corresponding  to  the  test-diet  may  be  indicated 
by  a  material  administered  for  the  purpose,  usually  soot  in  capsules, 
No.  oo  hard  gelatin  capsules  filled  with  soot  accomplishing  this  purpose; 
or  carmin  may  be  used,  5  grains  (0.3  gram)  in  a  capsule.  Either  of  these 
is  administered  at  the  beginning  of  the  first  meal  of  the  test-diet.  The 
subsequent  appearance  of  black  or  red  stool  indicates  that  the  intestinal 
contents  corresponding  ^to  the  special  diet  are  being  ejected. 

The  administration  of  a  special  substance  to  mark  the  stools  is,  in 
a  majority  of  instances,  not  absolutely  necessary,  the  diet  being  of  a  nature 
that  gives  rise  to  a  stool  sufl&ciently  distinctive  for  recognition.  Until 
the  observer  is  familiar  with  the  examination,  it  is  advisable  to  employ 
one  of  the  substances  mentioned. 

The  test-diet  to  be  employed  is  selected  to  meet  the  requirement 
that  it  shall  present  a  sufl&cient  quantity  of  all  classes  of  food  stuffs  to 
test  the  digestive  capacity,  that  the  digestive  processes  shall  not  be  unduly 
anticipated  in  the  preparation  of  the  food,  and  that  normally  very  little 
food  residue  shall  be  present  in  the  ejected  bowel  contents.  Naturally, 
the  stomach  plays  its  usual  part,  so  that  the  test  is  not  limited  to  the 
intestinal  tract  proper,  but  applies  to  alimentation  as  a  whole. 

The  test-diet  made  use  of  is  a  modification  of  the  original  Schmidt- 
Strassburger  diets.  Instead  of  three  diets,  as  were  originally  employed 
in  connection  with  the  fermentation  test  of  these  observers,  one  diet 
is  now  advocated  which  presents  the  conditions  essential  for  the  meat 
test.     This  diet,  as  recently  described  by  Schmidt,  is  as  follows: 

In  the  Morning. — 0.5   liter  milk,  or,  if  milk  does  not  agree,  0.5  liter  cocoa  (prepared 

from  20  gm.  cocoa  powder,  lo  gm.  sugar,  400  gm.  water,  and  100  gm.  milk),  to  this 

add  50  gm.  zwieback. 
In  the  Forenoon. — 0.5  liter  oatmeal  gruel — made  from  40  gm.  oatmeal,  10  gm.  butter, 

100  gm.  milk,  300  gm.  water,  i  egg — (strained). 
At  Noon. — 125  gm.  chopped  beef  (raw  weight),  broiled  rare  with  20  gm.  of  butter,  so 

that  the  interior  will  remain  raw;  to  this  add  250  gm.  potato  broth  (made  of  190  gm. 

mashed  potatoes,  100  gm.  milk,  and  10  gm.  butter). 
In  the  Afternoon. — As  in  the  morning. 
In  the  Evening.— As  in  the  forenoon. 

• 

This  diet  consists  of:  , 

1.5  liters  milk,  100  gm.  zwieback,  2  eggs,  50  gm.  butter.  152  gm.  beef,  190  gm. 
potatoes,  and  gruel  of  80  gm.  oatmeal. 

It  contains  about: 

102  gm.  albumin,  in  gm.  fat,  191  gm.  carbohydrates,  or  a  total  of  2234  calories 
(raw  calories). 

The  test  is  generally  given  for  three  days,  sometimes  longer;  at  any 
rate  until  a  stool  is  obtained,  which  comes  with  certainty  from  this  diet. 

Steele  advocates  an  arrangement  of  the  diet  to  conform  to  American 
dietary  habits,  which  still  maintains  the  essential  features  of  the  above. 
It  consists  of: 


TESTING    THE    INTESTINAL    FUNCTIONS  545 

2H  pints  milk,  3  ounces  well-dried  toast,  2  eggs,  I'/i  ounces  butter,  M  pound 
tender  rare  steak,  6  ounces  mashed  boiled  white  potato,  and  gruel  made  from  2!-^  ounces 
ordinary  oatmeal,  M  ounce  sugar. 

This  may  be  given  somewhat  as  follows: 

Breakfast. — 2  eggs,  one-third  of  the  amount  of  toast  and  butter,   2  glasses  of  milk, 

oatmeal,  and  sugar. 
Dinner. — The  steak  and  potato,  one-third  of   the  amount  of  toast  and  butter,  iVi  glasses 

of  milk. 
Supper. — 2  glasses  of  milk,  remainder  of  toast  and  butter. 

For  the  collection  of  the  stools,  where  they  are  not  to  be  transported 
for  any  considerable  distance,  an  ordinary  tin  basin  of  24-ounce  capacity 
serves  well  for  a  receptacle,  as  suggested  by  Prof.  L.  B.  Mendel.  This 
may  be  supplied  with  a  cover,  consisting  of  a  cake  tin  of  appropriate 
size;  or  where,  this  is  not  readily  provided,  a  small  pie  tin  may  be  used. 
This  outfit  is  inexpensive  (8  cents),  adequate,  and  where  a  considerable 
number  are  to  be  kept,  may  be  advantageously  stacked.  Moreover,  where 
the  stools  are  to  be  weighed  and  dried  for  exact  quantitative  analysis, 
this  may  be  directly  done  in  the  weighed  basins,  thus  avoiding  the  transfer 
of  the  specimens. 

If  the  feces  are  to  be  transported  for  any  considerable  distance,  a 
pint  glass  jar  (with  patent  air-tight  top)  serves  admirably  for  the  collec- 
tion. The  specimen  may  be  hermetically  sealed.  If  transported  in 
ordinary  wide-mouthed  bottles,  the  stoppers  should  be  tied  on,  as  gas 
formation  is  quite  likely  to  produce  sufl&cient  pressure  to  force  out  any 
stopper  not  securely  fastened. 

The  characteristics  of  the  test-diet  stool,  aside  from  the  coloration 
given  by  the  special  marking  substance  administered,  are  the  light  brown 
color  and  uniform  consistency.  It  usually  appears  at  the  second  or  third 
defecation  after  the  beginning  of  the  test-diet. 

The  period  of  time  required  for  the  passage  of  food  through  the  entire 
alimentary  tract  is  of  importance  and  is  readily  observed.  Normally 
it  takes  about  twenty-four  hours.  It  is  not  necessarily,  though  it  is 
commonly,  related  to  the  frequency  of  defecation.  In  some  cases  the 
stool  appears  with  regularity  and  is  fairly  copious,  yet  the  patient  suffers 
from  fecal  accumulation — a  latent  constipation.  The  period  of  passage 
may  suggest  the  seat  of  the  intestinal  disturbance  in  diarrhea,  since  it  is 
only  decidedly  increased  when  the  cause  is  high  up.  Strauss  has  shown 
that  chronic  colitis  may  be  accompanied  by  several  watery  movements 
a  day  with  a  normal  period  of  passage.  The  examination  of  the  collected 
stool  should  be  made  while  the  feces  are  perfectly  fresh. 

Macroscopic  Examination. — This  is  the  most  important  part  of  the 
procedure.  Experience  with  this  part  of  the  investigation  may  enable  the 
observer  to  at  once  recognize  some  defect  in  alimentation. 

Note  the  consistence,  color,  and  odor.  Inspect  the  surface  of  the 
formed  stool  for  morbid  products,  notably  for  pus,  blood,  and  mucus, 
which  are  to  be  removed  for  microscopic  and  bacteriologic  examination. 
Bits  of  tissue  from  some  diseased  area  may  also  be  sought  for,  but  their 
occurrence  is  so  unusual  that  it  is  exceptional  when  they  are  found. 
35 


546  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

The  mass  of  feces  is  then  well  mixed,  for  which  procedure  a  wooden 
or  tin-plate  spoon  is  useful;  and  a  piece  the  size  of  a  walnut  transferred 
to  a  mortar,  in  which  it  is  thoroughly  but  not  forcibly  ground  with  dis- 
tilled water  added  gradually  until  the  whole  is  of  a  uniform  fluid  consist- 
ency and  no  small  masses  of  fecal  matter  remain.  The  fluid  feces  is  then 
examined  in  thin  layers,  conveniently  in  a  Petri  or  similar  larger  dish, 
against  a  black  background,  with  the  naked  eye  or  low-power  magnifying 
glass,  for  all  elements  that  may  be  differentiated.  In  normal  digestion 
only  a  few  brown  points,  smaller  than  pin-heads  will  appear,  these  consisting 
of  chaffy  remains  of  oatmeal  gruel  and  remains  of  cocoa,  if  this  latter  has 
been  taken.     Under  pathologic  conditions,  there  may  be  present: 

1.  Mucus,  which  appears  usually  as  larger  or  smaller,  soft,  glossy, 
translucent  flakes,  often  bile  stained;  infrequently,  when  from  the  large 
intestine,  white  or  brown,  with  a  gummy  or  almost  leathery  hardness. 

2.  Pus,  blood,  parasites,  stones,  and  other  foreign  bodies. 

3.  Connective  tissue  and  tendons,  distinguished  by  their  whitish- 
yellow  color,  thread-like  appearance,  and  solid  consistence. 

4.  Muscular  tissue,  chiefly  in  very  small,  brown  colored  rods,  like 
splinters  of  wood. 

5.  Potato,  appearing  like  boiled  tapioca  grains,  readily  confused 
with  flakes  of  mucus.     The  distinction  is  made  with  the  microscope. 

6.  Large  crystals  of  ammoniomagnesium  phosphate,  which  grate 
when  the  specimen  is  ground. 

Microscopic  Examination. — This  serves  chiefly  to  complete  the  gross 
inspection.  In  addition  to  the  preparations  of  material  selected  during 
the  macroscopic  examination,  three  slide  preparations  are  made.  The 
first  consists  merely  of  a  drop  of  the  liquefied  stool  under  the  cover-glass. 
The  second,  a  drop  of  the  liquefied  stool  mixed  with  a  drop  of  acetic  acid, 
heated  to  the  beginning  of  boiling  and  covered  with  a  cover-glass.  The 
third  consists  of  a  drop  of  the  liquefied  stool  mixed  with  potassium  iodid 
solution  of  iodin  and  covered  with  a  cover-glass. 

Inspection  of  the  first  slide  preparation  by  the  aid  of  the  microscope, 
using  a  high,  dry  lens,  reveals  finely  divided  material  consisting  of  bacteria 
and  mostly  unrecognizable  detritus,  in  which  are  imbedded: 

(a)  Isolated  fragments  of  muscle-fibers,  usually  bile  stained,  partially 
digested,  but  occasionally  with  the  transverse  sl.riations  recognizable. 

{b)  Larger  or  smaller  yellow  crystals  of  the  alkali  earth  salts  of  the 
fatty  acids. 

(c)  Colorless  soaps. 

{d)  Isolated  potato  cells,  without  distinguishable  contents. 

(e)  Particles  of  oatmeal  and  cocoa  shells,  where  the  latter  is  taken 
instead  of  milk. 

The  second  slide  gives  a  general  idea  of  the  fat  present  in  the  stool. 
While  hot,  the  fatty  acids,  liberated  in  the  acetic  acid,  appear  as  drops; 
on  cooling,  these  congeal  to  small  needle-like  crystals. 

In  the  third  preparation  potato  remains  have  a  violet  color,  while 
isolated  fungous  spores  (Clostridium  butyricum)  may  appear  blue. 

The  pathologic  findings  which  the  slide  may  present,  in  addition  to 
those  enumerated  under  the  macroscopic  examination,  are: 


TESTING    THE   INTESTINAL   FUNCTIONS  547 

Slide  I. — Muscle  fragments  in  greater  number  and  better  state  of  preservation,  par- 
ticularly with  retained  nuclei;  drops  of  neutral  fat;  needles  of  fatty  acids  and  soaps; 
many  groups  of  potato  cells. 

Slide  II. — Massive  fatty  acid  drops  and  crystals. 

Slide  III. — Blue  starch  grains,  free  or  in  the  potato  cells;  oatmeal  cells;  any  considerable 
number  of  blue-staining  fungous  spores  or  thread-like  bacteria. 

Bacteriologic  Examination. — The  recognition  of  the  tubercle  typhoid, 
Shiga,  or  cholera  bacillus  calls  for  technic  which  will  be  found  described 
in  special  treatises.  The  selection  of  material  to  be  examined  for  tubercle 
bacilli  is  best  made  from  the  surface  of  formed  stools,  since  in  soft  move- 
ments morbid  products  from  the  diseased  area  will  be  so  mixed  with  the 
feces  as  to  easily  escape  detection. 

For  amebge,  a  saline  cathartic  such  as  magnesium  sulphate  should  be 
given  and  the  warm  liquid  stool  examined.  The  stool  to  which  several 
ounces  of  normal  saline  at  ioi°F.  is  added  may  be  kept  warm  in  a  Thermos 
bottle  for  transportation  to  the  laboratory.  Mention  has  already  been 
made  of  the  detection  of  bacteria  and  fungi  which  are  colored  blue  by 
iodin  (granulose  reaction). 

Procedures  that  yield  information  of  considerable  value  in  the  less 
specific  forms  of  intestinal  infection  have  recently  been  advocated  by 
Herter.  Of  first  importance  is  the  preparation  of  smears  of  the  mixed 
stools  on  microscopic  slides,  stained  by  the  Gram  method.  The  relative 
number  of  Gram-positive  bacteria,  as  also  their  character,  is  of  diagnostic 
value,  since  they  are  relatively  few  in  health  and  in  meat-free  diet,  while 
they  are  increased  in  some  diseased  conditions  and  when  notable  quantities 
of  meat  are  eaten.  Not  only  is  it  of  value  to  note  the  actual  increase, 
but  the  potential.  The  latter  is  determined  by  the  observation  of  the 
relative  number  of  Gram-positive  bacteria  in  the  residues  in  the  sugar- 
bouillon  tubes  (see  below),  a  predominance  of  Gram-positive  bacteria 
indicating  a  pathologic  tendency  of  the  fecal  flora.  Among  the  various 
bacteria  that  may  be  observed  it  is  well  to  have  in  mind  that  B.  coli  are 
Gram-negative,  usually  small  bacilli  that  may  even  appear  almost  like 
diplococci;  that  B.  bifidus  are  Gram-positive  bacilli  usually  some  of  which 
appear  forked;  that  the  pyogenic  cocci  are  in  general  Gram-positive;  and 
that  Gram-negative  cocci  are  ordinarily  to  be  regarded  as  saprophytic. 

The  sugar-bouillon  tubes  just  mentioned  are  ordinary  fermentation 
tubes,  containing  i  per  cent,  lactose-bouillon,  i  per  cent,  glucose-bouillon, 
and  I  per  cent,  saccharose-bouillon  respectively. 

Normally,  little  fermentation  occurs  when  the  tubes  have  been  in- 
cubated at  37°C.  for  tv/enty  to  twenty-two  hours.  Active  gas  pro- 
duction, so  that  it  accumulates  to  the  extent  of  more  than  one-third  of 
the  tube  capacity,  is  most  frequently  due  to  the  predominance  of  a  bacillus 
identical  with  or  allied  to  the  Gram-positive  Bacillus  aerogenes  capsulatus, 
the  growth  of  which  replaces  the  Bacillus  coli  communis,  the  normal  in- 
testinal inhabitant. 

For  more  exact  quantitative  bacteriological  examination,  the  following 
procedures  may  be  employed: 

One  gram  of  the  representative  fecal  matter  is  accurately  weighed  out 
with  an  analytical  balance  of  precision,  in  a  sterile  small  glass  crystallizing 


548  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

dish.  This  material  is  then  tritrated  with  successive  small  portions  of  sterile 
water  by  the  aid  of  a  sterile  glass  rod  with  rounded  end,  transferring  each 
portion  of  the  suspension  to  a  small  weighed  Erlenmeyer  flask  containing 
glass  beads,  continuing  the  procedure  till  after  five  or  six  such  transfers 
the  entire  sample  has  been  transferred  and  the  suspension  in  the  flask  has 
been  accurately  brought  to  20  grams.  The  suspension  is  further  pro- 
moted by  rotating  the  flask  for  ten  minutes  or  longer  as  necessary,  to 
allow  the  beads  to  completely  subdivide  the  suspended  particles.     This  is: 

Suspension  A,  of  which  each  c.c.  contains  50  mgr.  of  feces. 

Suspension  B  is  prepared  by  diluting  10  c.c.  of  A  to  100  c.c,  each  c.c.  containing  s  mgr. 
Suspension  C  is  prepared  by  similarly  diluting  10  c.c.  of  B,  each  c.c.  containing  0.5  mgr. 
Suspension  D  is  prepared  by  similarly  diluting  10  c.c.  of  C,  each  c.c.  containing  0.05  mgr. 
Suspension  E  is  prepared  by  diluting  i  c.c.  of  C  to  100  c.c,  each  c.c  containing  0.005  mgr- 

1.  Total  number  of  bacteria.  Winterberg  Method.  A  one  to  ten 
dilution  with  weak  carbol-fuchsin  (Ziehl's,  diluted  i  :  10)  is  made  of  sus- 
pension B  in  a  white  blood-counting  pipette  and  transferred  to  a  Thoma- 
Zeiss  chamber  in  which  the  count  is  made.  The  average  number  per  small 
square  multiplied  by  8  is  the  number  of  million  bacteria  per  milligram  of 
fresh  feces. 

2.  Number  of  living  bacteria  cultivable  in  lactose-litmus-agar  at  37°C. 
growth  in  air  and  in  hydrogen.  For  the  aerobic  bacteria,  }^i  c.c.  of  sus- 
pension E  corresponding  to  0.0025  mgr.  feces  is  employed  for  each  plate. 
The  number  of  colonies  multiplied  by  0.4  is  the  number  of  thousand  per 
milligram  of  fresh  feces. 

For  the  anaerobic  bacteria,  i  c.c.  of  suspension  E,  corresponding  to 
0.005  n^g-  feces  is  employed  for  each  plate.  The  number  of  colonies 
multiplied  by  0.2  is  the  number  of  thousand  per  milligram  of  feces. 

3.  The  number  of  living  bacteria  cultivable  in  lactose-litmus-gelatin 
at  2o°C.,  growth  in  air  and  in  hydrogen.  For  the  aerobic  bacteria,  H 
c.c.  of  suspension  E,  corresponding  to  0.0025  mgr.  feces,  is  employed  for 
each  plate.  The  number  of  colonies  multiplied  by  0.4  is  the  number  of 
thousand  bacteria  per  milligram  of  fresh  feces. 

For  the  anaerobic,  i  c.c.  of  suspension  E,  corresponding  to  0.005  ^g- 
feces  is  employed  for  each  plate.  The  number  of  colonies  multiplied  by 
0.2  is  the  number  of  thousand  per  milligram  of  feces.  In  each  case  the 
differentiation  into  liquefiers  and  non-liquefiers  is  made  during  the  count. 

4.  The  number  of  living  spore  forms.  For  the  aerobic  spore  forms, 
I  c.c.  of  suspension  C,  corresponding  to  0.5  mgr.  is  heated  for  ten  to  fifteen 
minutes  at  8o°C.  and  then  plated  in  lactose-litmus-agar  and  grown  at 
37°C.  The  number  of  colonies  multiplied  by  2  is  the  number  of  aerobic 
spores  per  milligram  of  feces. 

For  the  anaerobic  spore  forms,  i  c.c.  of  suspension  D,  corresponding  to 
0.05  mg.  is  heated  as  above,  plated  in  lactose-litmus-agar  and  grown  in 
hydrogen  at  37°C.  The  number  of  colonies  multiplied  by  20  is  the  number 
of  anaerobic  spores  per  milligram  of  feces. 

5.  The  relative  number  of  Gram-negative  and  positive.  Films  are 
prepared  from  one  of  the  suspensions,  usually  B,  air-dried,  fixed,  stained 
with  aniline-gentian-violet  for  one  and  one-fourth  minutes,  washed  with 
Lugol's  solution  and  covered  with  same  for  one  minute,  decolorized  with 


TESTING    THE   INTESTINAL   FUNCTIONS 


549 


95  per  cent,  alcohol  for  thirty  minutes,  washed  with  distilled  water,  stained 
with  I  per  cent.  Bismark  brown  one  and  three-fourths  minutes,  washed, 
dried  and  if  desired  mounted  in  balsam.  The  count  is  made  by  the  aid  of 
an  eye  piece  marked  off  in  squares. 

6.  The  relative  number  of  cocci,  bacilli  and  spirillae,  etc.,  in  the  original 
fecal  material.  This  is  determined  by  an  independent  differential  count 
of  the  film  prepared  under  5. 

7.  Quantity  of  gas  production.     Fermentation  is  conducted  in  i  per 
cent,  glucose  bouillon,  inoculated  with  two  loops  of  sus- 
pension A,  and  kept  at  37°C.  for  forty-eight  hours.     Gas  V  ^ 
formation  is  measured  as  usual  in  the  closed  limb  of  the 
tube. 

8.  The  relative  number  of  cocci,  bacilli  and  spirillae, 
etc.,  developed  during  fermentation.  This  is  determined 
from  the  count  of  a  film  prepared  from  the  sediment  of 
the  fermentation  tube  and  stained,  as  described  under  5. 

Chemic  Examination.— The  chemic  reaction  is  best 
determined  by  smearing  one  side  only  of  moistened  red 
and  blue  litmus-paper  with  the  diluted  (see  Macroscopic 
Examination)  fecal  matter.  After  some  time  the  reaction 
is  noted  on  the  opposite  side.  It  is  usually  amphoteric, 
feebly  acid,  or  alkahne. 

Excretion  of  Bile. — The  sublimate  test  for  unchanged 
bile-pigment  is  performed  by  adding  some  of  the  diluted 
fecal  matter  to  a  considerable  excess  of  strong  solution 
of  bichlorid  of  mercury,  allowing  the  mixture  to  stand 
over  night.  The  normal  feces  are  colored  red;  more  in- 
tensely, the  fresher  and  less  decomposed  the  excrement. 
Herter  points  out  that  this  red  coloration  may  be  patho- 
logically increased  in  excessive  saccharobutyric  putrefac- 
tion. This  excessively  strong  reaction  is  probably  due 
to  the  reduction  of  the  bilirubin  to  hydrobilirubin  through 
the  Bacillus  aerogenes  capsulatus.  In  the  presence  of 
bilirubin,  a  green  coloration  is  produced.  This,  even  to 
the  extent  of  microscopically  small  particles,  is  patho- 
logic. A  negative  sublimate  test  suggests  suppression  of  bile.  This  last  is. 
of  value,  as  it  indicates  that  an  acholic  stool  is  bile  free  and  that  the  color- 
less stool  is  due  to  complete  occlusion  of  bile  from  the  intestines.  An  in- 
complete test  with  fresh  stools  shows  abnormal  processes  of  decomposition. 

Functions  of  the  Liver. — The  best  method  of  testing  the  functions  of  the 
liver  depends  on  the  power  of  the  normal  liver  to  metabolize  100  grams  of 
levulose  when  given  all  at  once  in  solution,  as  in  weak  coffee,  on  an  empty 
stomach.  Normally,  no  trace  of  this  should  appear  in  the  urine  by  Fehl- 
ing's  test.     The  urine  should  be  first  examined  six  hours  after  its  ingestion. 

The  fermentation  test  of  Schmidt  and  Strassburger  for  fermentable 
carbohydrate  or  putrescible  protein  is  performed  in  the  Strassburger 
fermentation  tube  (Fig.  264). 

A  5-gram  portion  of  the  well-mixed,  undiluted,  fresh  excrement,  or 
proportionally  more  of  the  thinner  material,  is  well  mixed  with  sterile 


Fig.  264. — S  trass- 
burger's  tube. 


550  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

water;  the  chemic  reaction  noted;  and  then  the  mixture  is  introduced 
into  the  lower  vessel  of  the  apparatus. 

The  bottle  is  entirely  filled  with  water  and  stoppered,  with  exclusion 
of  air.  The  adjacent  upper  tube  is  filled  or  nearly  filled  with  water, 
while  the  distal  tube  remains  empty.  The  apparatus  is  incubated  at  37°C. 
for  twenty-four  hours. 

The  extent  of  gas  formation  is  indicated  by  the  amount  of  water  dis- 
placed by  the  gas  from  h'  and  which  accumulates  in  the  distal  tube  c'. 
Normally,  there  is  practically  no  gas  formation,  and  the  chemic  reaction 
of  the  fecal  mixture  remains  about  unchanged.  Gas  production  to  such 
an  extent  as  to  introduce  an  amount  of  water  into  the  distal  tube  equal 
to  one-third  its  capacity  is  pathologic.  If  coincidently  with  the  gas  pro- 
duction the  chemic  reaction  has  developed  a  decidedly  increased  acidity, 
the  gas  production  is  due  to  carbohydrate  fermentation;  if  alkalinity, 
albuminous  putrefaction  has  occurred.  When  the  proximal  tube  is 
opened  it  gives  off  a  butyric  acid  odor  in  the  former  case  and  a  putrefactive 
odor  in  the  latter.  The  color  of  fermenting  feces  is  generally  brighter;  of 
putrefying  feces,  darker.  The  test  is  more  especially  applicable  to  the 
test-diet  stools. 

If  the  condition  approximates  the  normal,  a  further  test  should  be 
carried  out  for  accuracy.  In  such  event,  the  patient  is  placed  on  a  diet 
which  differs  only  from  the  first  in  the  absence  of  meat  and  potato.  If 
there  is  still  a  positive  result,. the  diagnosis  of  "fermentative  dyspepsia" 
is  justifiable. 

Putrefactive  Products. — Tests  for  indol  and  skatol  may  be  applied 
to  the  distillate,  using  lo  gm.  of  the  feces  mixed  with  120  c.c.  of  water, 
and  the  whole  made  alkaline,  a  bit  of  paraffin  added  to  prevent  frothing, 
and  the  first  50  c.c.  collected. 

A  suitable  apparatus  for  conducting  the  process  consists  of  a  500-c.c. 
capacity  long-neck  Kjeldahl  digestion  flask  connected  with  a  Liebig  con- 
denser. Distillation  with  steam  is  sometimes  advantageous;  10  c.c.  of 
the  distillate  is  rendered  slightly  alkaline  with  sodium  or  potassium 
hydroxid  and  an  excess  of  a  fresh  solution  of  betanaphthoquinone-sodium- 
monosulphonate  added.  The  substance,  in  the  course  of  a  few  minutes, 
reacts  almost  completely  with  the  indol  present,  but  not  with  the  skatol; 
.with  the  resulting  formation  of  a  bluish  precipitate  with  much  indol,  and 
a  mere  coloration  of  the  solution  with  little.  If  more  than  a  trace  is  pres- 
ent, the  reaction  is  conducted  with  the  remaining  40  c.c.  of  the  distillate, 
the  indol naphthaquinone  compound  removed  from  the  whole  by  filtra- 
tion, and  from  the  portion  remaining  in  solution  by  distillation,  after 
acidifying. 

The  distillate  containing  the  skatol,  if  necessary,  freed  from  indol 
as  described,  is  tested  by  the  use  of  a  well-marked  excess  of  dimethyl- 
amido-benzaldehyd  (Ehrlich's  aldehyd),  being  boiled  with  a  5  per  cent, 
solution  in.  10  per  cent,  sulphuric  acid.  Dilute  hydrochloric  acid  is  added 
to  the  point  of  the  production  of  the  maximum  color  intensity  and  the 
mixture  rapidly  cooled.  The  presence  of  skatol  is  indicated  by  the  blue 
coloration.     The  color  may  with  advantage  be  extracted  with  chloroform. 

If  the  process  described  is  to  be  conducted  quantitatively,  25  grams 


TESTING   THE   INTESTINAL   FUNCTIONS  55 1 

of  feces  should  be  employed^  and  distillation  continued  till  the  distillate 
is  free  from  substances  reacting  with  the  above  reagents,  the  color  shaken 
out  wit'h  known  volumes  of  chloroform,  and  the  depth  of  color  compared 
by  the  aid  of  the  Duboscq  colorimeter,  with  a  similar  chloroform  extract 
obtained  by  starting  with  solutions  of  known  strength  of  indol  and  skatol 
respectively. 

REFERENCES 

Herter,  C.  A.,  Bacterial  Infections  of  the  Digestive  Tract,  1907. 

Herter,  C.  A.,  and  Foster,  M.  Louise,  Jour  of  Biol.  Chem.,  i.  p.  257;  ii,  p.  267. 

Schmidt,  A.,  translated  by  C.  D.  Aaron,  The  Test-diet  in  Intestinal  Diseases,  vol. 

Ixxvii,  1906. 
Steele,  J.  Dutton,  Medical  News,  1905,  p.  1158,  vol.  Ixxvii. 

Results. — In  interpretation  of  results,  we  have  to  consider  both 
the  occurrence  of  pathologic  admixtures  and  an  increase  of  the  constit- 
uents frorh  the  test-diet. 

A  thin  coating  of  mucus  is  normally  collected  by  the  hardened  fecal 
matter.  Otherwise  the  appearance  of  this  product  indicates  catarrh  of 
the  mucosa,  the  mucus  containing  many  cellular  elements.  An  exception 
is  the  overproduction  of  mucus  in  colica  mucosa,  with  cellular  elements 
less  abundant  and  with  the  striking  consistence. 

Pus,  blood,  masses  of  epithelia  from  the  mucosa,  and  similar  elements 
carry  the  pathologic  significance  of  these  products,  and  require  investiga- 
tion and  interpretation,  as  when  found  elsfewhere. 

Considering  an  increase  of  the  constituents  of  the  test-diet,  a  dis- 
tinct connective-tissue  increase  indicates ,  deficient  gastric^  digestion. 
An  excessive  quantity  of  meat-fibers  points  to  deficient  protein  digestion 
in  the  small  intestine.  The  albumin  fermentation  (putrefactive)  test 
further  indicates  increased  protein  in  stools,  frequently  derived  from 
pathologic  secretions,  probably  associated  with  an  abnormal  putrefactive 
flora.  The  bacteriologic  examination,  especially  as  to  fermenting  and 
Gram-positive  bacteria,  is  of  value  along  these  lines.  Also  test  for  pu- 
trefactive products,  if  increased  activity  in  this  direction'  m  the  stool  itself 
is  to  be  investigated. 

Starch  granules,  revealed  microscopically,  show  deficient  starch 
digestion  in  the  intestines,  due  either  to  rapid  passage  of  the  contents  or 
disturbed  secretion.  Defective  carbohydrate  digestion  is  also  indicated 
by  an  abnormal  carbohydrate  fermentation  test. 

Only  a  considerable  increase  of  fat  is  pathologic.  Such  a  stool  is 
indicated  by  the  quantity  of  the  stool  itself,  the  light  (whitish)  color, 
and  a  marked  acid  reaction,  as  well  as  by  the  microscopic  findings.  A 
deficient  flow  of  bile  or  of  pancreatic  secretion  is  the  usual  cause;  in  the 
former  case  the  stool  not  containing  pigment  (sublimate  test) ;  in  the  latter 
showing  an  associated  increase  of  meat-fibers,  frequently  with  retained 
nuclei.  Functional  disturbances  of  fat  digestion  are  said  to  occur,  but 
other  possibilities  must  be  excluded  in  reaching  this  diagnosis. 

As  to  the  bacteria  in  the  fecal  matter  of  an  adult  on  an  ordinary  diet, 
a  total  of  20  million  bacteria  per  milligram  may  be  regarded  as  small,  40 

^  The  author  advocates  a  separate  test  of  the  gastric  functions. 


552  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

to  60  as  moderate  and  over  80  as  large.  Living  aerobes  and  anaerobes 
(37°C.)  to  the  number  of  10,000  each  may  be  found  in  low  count  stools, 
100,000  to  200,000  each  in  moderate  and  400,000  each  and  over  in  high 
coimt  stools.  Growth  at  2o°C.  yields,  as  a  rule,  lower  results.  Liquefiers 
are  relatively  few  in  the  normal  adult.  Ten  spores  per  milligram  is  a  com- 
mon number,  the  anaerobes  being  as  a  rule  more  abundant.  Ordinarily 
the  Gram-negative  are  twice  as  abundant  as  the  Gram-positive  bacteria 
and  the  bacilli  outnumber  the  cocci. 

MECHANICAL  PROCEDURES 

Direct  Lavage  of  the  Duodenum. — This  method  has  been  suggested 
by  Gross,  ^  by  the  employment  of  his  duodenal  tube.  Siphonage  is  em- 
ployed as  in  lavage,  but  is  unpractical  and  Jutte  has  improved  upon  it  by 
employing  a  fountain  syringe,  hanging  it  low  and  allowing  a  small  stream 
to  flow  in  slowly  so  not  to  cause  overdistention  or  pain.  No  attempt  at 
siphonage  is  made,  and  the  solution  flows  at  least  part  way  through  the 
small  intestine.  If  magnesium  sulphate  or  some  other  saline  cathartic 
is  added  to  normal  saline  solution,  the  effect  is  more  active.  The 
duodenal  tube  is  passed  with  the  patient  sitting  and  he  then  lies  on  the 
right  side  and  the  tube  is  fed  in  gradually  as  described  under  Testing 
the  Functions  of  the  Pancreas.  A  few  swallows  of  water  are  administered 
while  swallowing  the  tube  to  aid  its  passage.  As  no  preliminary  test- 
meal  is  given,  one  cannot  always  prove  its  entrance  by  aspirating  duodenal 
contents  and  in  some  cases  they  are  difficult  to  secure.  One  can  at  the  end 
of  an  hour^  administer  a  little  milk  and  then  see  if  it  can  be  aspirated. 
This  sometimes  curdles  and  hence  a  small  amount  of  weak  tea  or  a  glass  of 
water  stained  with  a  pinch  (gr.  v)  of  methylene  blue,  or  carmine,  or  a  weak 
alkaline  solution  of  fluorescein  can  be  given.  If  no  colored  fluid  is  aspirated 
it  is  evident  that  the  tube  has  passed  through  the  stomach.  The  tempera- 
ture of  the  irrigating  fluid  should  be  101°  to  io2°F.  The  method  is  of  use 
in  the  following  conditions:  In  obstinate  jaundice  from  duodenal  catarrh, 
irrigation  two  or  three  times  a  week  of  the  duodenum  with  a  liter  of  normal 
saline  solution  containing  5  ss  to  5  i  of  soda  bicarbonate  or  5  ss  to  5  i  or  milk 
of  magnesia  or  5  ii  of  magnesia  usta  would  help  clean  off  the  mucus  and 
magnesia  preparations  aid  bowel  action.  Duodenal  lavage  could  be 
employed  in  severe  or  persistent  attacks  of  intestinal  toxemia,  and  could 
be  tried  in  marked  urticarial  attacks  with  or  without  associated  asthma — 
such  as  are  believed  due  to  protein  absorption  (anaphylaxis).  In  such  cases 
a  preliminary  large  dose  of  magnesium  sulphate  5  i  could  be  given  in  01 
water  or  saline  solution  through  the  duodenal  tube  for  rapid  effect, 
a  previous  dose  (four  hours  before)  of  calomel  gr.  v  having  been 
administered. 

Subsequently  irrigation  with  i  quart  of  acetozone,  i :  1000,  or  5  i  of 

hydrogen  peroxid  (3  per  cent.)  in  i  liter  (quart)  of  water,  or  with  normal 

saline  solution,  or  with  i  :  2500  permanganate  of  potash  can  be  carried  out 

several   times   a  week,  in  addition  to  enteroclysis  by  the  anal  route, 

hexamethylenamine  gr.  v.  to  x  t.i.d.  by  mouth,  sour  milk,  etc. 

^  X.  Y.  Med.  Jour.,  Jan.  28,  191 1. 

*  Sometimes  several  hours  will  elapse  before  the  tube  enters  the  duodenum  (6-12 
hours)  and  if  pyloric  stenosis,  it  may  not  enter  it  at  all. 


MECHANICAL    PROCEDURES  553 

Ellice  McDonald  reports  for  duodenal  lavage  a  special  antiseptic 
solution  (trimethyl  methoxy-phenol  in  gelatin  emulsion)^  to  which  3iv-5vi 
granulated  sod.  sulphate  in  water,  i  liter  are  added  and  the  subsequent 
rapidly  evacuated  material  proved  sterile;  the  external  surface  of  some 
fecal  material  contained  therein  also  proving  sterile.  He  claims  thus  the 
possibility  of  sterilizing  the  intestinal  tract.  There  is  no  proof  of  sterili- 
zation of  the  mucosa,  an  important  feature  though  nearly  complete 
sterilization  of  intestinal  contents  was  reported  by  Sondern. 

Future  reports  may  show  whether  any  damage  (irritation)  to  the 
mucosa  results  and  to  what  extent  the  cases  received  benefit. 

In  severe  and  obstinate  cases  of  fecal  impaction,  the  injection  of 
large  quantities  of  olive  oil,  such  as  half  a  pint  or  more,  or  5ii  to  5iv  of 
Russian  mineral  oil  or  large  doses  of  saline  cathartics  (which  undoubtedly 
would  be  vomited  if  taken  by  mouth)  would  prove  of  value  when  injected 
through  the  duodenal  tube. 

The  Enema;  Intestinal  Irrigation;  Proctoclysis. — For  injection  into 
or  irrigation  of  the  intestines  there  are  Jour  methods,  all  of  which  have 
their  special  applications.     They  are: 

1.  The  enema. 

2.  Irrigation  with  a  single  tube. 

3.  Irrigation  with  a  double-current  tube  or  with  two  tubes. 

4.  Proctoclysis,  the  drop  method  of  injection. 

Uses  of  irrigations  or  enemata  are  as  follows:  The  local  treatment  of 
diseased  conditions,  as  of  catarrhal  colitis. 

The  relief  of  congestion  or  acute  inflammation,  as  of  the  rectum  or 
prostate. 

The  relief  of  pain  and  irritability,  as  in  spasm  of  the  sphincter,  or  of  an 
adjacent  organ  as  the  bladder. 

The  absorption  of  inflammatory  products,  as  of  postuterine  adhesions. 

To  replace  the  loss  of  fluid  in  the  body,  as  in  cholera. 

To  dilute  the  poison  of  disease,  as  in  uremia. 

To  increase  the  flow  of  blood  to  a  part,  as  in  insufficient  menstruation. 

To  check  hemorrhage  (extreme  cold  or  heat).  Locally,  as  in  bleeding 
ulcers  of  the  rectum;  in  an  adjacent  organ,  as  in  uterine  hemorrhage. 

Reflex  effects  through  the  sympathetic  ganglia,  on  the  circulatory 
apparatus,  on  the  secretions,  as  a  tonic  stimulant,  and  the  revulsive  effects. 
On  the  circulatory  apparatus,  as  in  shock.  On  the  secretions,  as  in  the 
production  of  sweating,  bowel  action,  and  urinary  secretion  in  uremia. 
As  a  tonic  stimulant,  as  by  use  of  the  alternate  hot  and  cold  douche  in 
diminution  of  erectile  power,  or  effect  on  the  musculature,  as  in  atonic 
constipation  or  impaction.  The  revulsive  effect,  as  the  production  of 
bowel  action  in  apoplexy.  The  reflex  effect  on  a  distant  organ,  as  from 
enemata  in  jaundice. 

The  effect  on  the  heat  centers — the  temperature  can  be  raised  in  shock 
by  hot  irrigation,  or  lowered  in  fever  by  cold  irrigation  or  by  enemata. 

Simple  cleanliness,  removing  undigested  food  products,  and  preventing 
auto-intoxication. 

Antispasmodic,  as  by  relieving  spasm  in  colic. 

*J.  T.  Ainslie  Walker,  American  Medicine,  vol.  x,  No.  9,  pp.  594-598,  Sept.,  1914. 


554 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


Mechanical,  as  in  intussusception. 

Water  as  a  vehicle — the  nutritive  enema,  or  for  medicaments. 

Physiologic  Experiments. — In  a  series  of  experiments  at  Columbia 
University  some  years  ago  the  author  demonstrated  on  animals  (Fig. 
265),  and  later  clinically,  that  enteroclysis  at  110°  to  i20°F.  best  stimulated 
the  heart  in  shock;  that  renal  secretion  undergoes  a  double  cycle  of  increase 
from  enteroclysis  at  high  temperatures  (i  10°  to  1 20°F.) ,  both  from  intestinal 
absorption  and  from  the  increased  blood  flow  through  the  kidney;  while 
with  lower  temperatures  the  increase  is  merely  from  intestinal  absorption. 

Normal  saline  solution  has  a  specific  efifect  in  increasing  renal  secre- 
tion. Cold  irrigations  first  stimulate,  then  depress.  Body  and  blood 
temperature  are  increased  by  hot  irrigations  and  diminished  by  cold. 

These  experiments^  were  completely  reported. 


Fig.   265. — Method  of  performing  physiologic  experiments. 


I.  Enema. — The  enema  may  be  high,  with  a  colon-tube  (Fig.  266), 
which  should  be  thoroughly  lubricated  and  the  water  should  flow  while 
inserting.  It  should  be  administered  with  the  patient  on  the  left  side, 
the  dorsal  position,  with  the  hips  elevated,  can  be  employed,  or,  for  high 
injection,  in  the  knee-chest  posture,  when  a  high  enema  can  thus  be  given 
with  a  short  tip.      I  prefer  never  to  give  more  than  i  to  i>^  quarts  (liters). 

Milder  medicated  solutions  can  be  employed  in  this  way.  The  low 
enema  is  of  more  value  for  low  impaction,  or  to  relieve  local  irritation  in 
the  rectum  or  adjacent  organs  (prostate,  bladder,  tubes,  ovaries). 

3.  Irrigation  with  a  Single  Tube. — There  are  four  modifications  of  this 
method : 

(a)  A  colon-tube  is  inserted  into  the  bowel,  a  funnel  attached,  and 
by  raising  and  lowering  the  funnel  the  bowel  is  washed  out. 

"^  Enteroclysis,  Hypodermoclysis,  and  Infusion,  Kemp;  Hydrotherapy,  S.  Baruch; 
Enteroclysis,  Reference  Handbook  of  the  Medical  Sciences,  1900  and  19 15. 


MECHANICAL    PROCEDURES 


3D:) 


(6)  A  fountain  syringe  can  be  attached  to  the  colon-tube,  and  when 
sufficient  fluid  has  flowed  in  from  the  fountain  syringe,  the  connection  is 
detached  and  the  fluid  flows  out  through  the  colon-tube. 

(c)  The  patient  can  void  the  fluid  around  the  colon-tube  or  catheter 


Fig.   266. — Colon-tube. 

during  irrigation.  This  is  the  method  usually  employed  with  infants. 
Elmer  Lee  carried  out  this  technic  at  the  cholera  stations  (Fig.  267). 
An  irrigating  jar  may  be  substituted  for  the  rubber  bag. 

(d)  A  glass  Y  or  T  tube^  is  attached  to  the  colon-tube,  as  in  lavage 
of  the  stomach;  one  branch  is  connected  with  the  fountain  syringe,  the 


Fig.  267. — Lee's  cholera  table. 


Other  is  to  a  soft  carry-off  tube.     By  alternately  pinching  the  soft-rubber 
outflow  and  inflow  tubes,  the  bowel  can  be  irrigated. 

4.  Double-current  Irrigation  with  Two  Tubes  or  a  Recurrent  Tube. — 

'  Enteroclysis,  Hypodermoclysis,  and  Infusion,  Kemp;  published  by  J.  T.  Dougherty, 


1900. 


556 


DISEASES    OF    THE    STOMACH   AND    INTESTINES 


Advantages. — The  quantity  of  the  fluid  is  under  the  control  of  the  operator, 
since  it  can  be  regulated  by  manipulation  of  the  outflow  and  inflow- 
tubes. 

The  labor  is  placed  upon  the  operator  and  not  upon  the  patient,  and 
there  is  no  straining  to  overcome  the  resistance  of  the  sphincter.  The 
straining  of  self-evacuation  is  avoided,  and  mere  mechanical  cleansing 
of  the  bowel  is  employed.  The  temperature  of  the  fluid  entering  the 
bowel  can  be  kept  constant. 


Fig.   268. — Kemp's  flexible  recurrent  rectal  irrigator. 

Tympanites  is  relieved  best  by  this  method,  the  return  flow  carries 
off  the  gas  by  suction.  With  the  enema  the  gas  frequently  collects  in  the 
intestines  behind  the  injection  and  it  is  often  impossible  to  exert  sufhcient 
force  to  expel  it  with  the  enema. 

Two  catheters  or  two  small  rectal  tubes  passed  through  a  perineal 
pad  can  be  improvised  for  this  purpose.  The  illustrations  of  the  author's 
tubes  are  shown  (Figs.  268-272).  They  are  readily  understood.  J.  P. 
Tuttle's,  Hemmeter's,  and  various  recurrent  rectal  tubes  are  described 


Fig.  269. — Kemp's  glass  rectal  irrigator  (recurrent).     Cork  opening  above  for  cleansing. 


by  the  author  in  his  manual  "Enteroclysis."  The  hard-rubber  tube  with 
metal  center  is  the  best.     All  metal  tubes  are  good  for  hospital  work. 

The  flexible  tube  is  excellent  for  sensitive  cases,  or  for  young  children. 

To  the  middle  tube  of  the  irrigator  is  attached  the  tube  of  the  fountain 
syringe;  to  the  curved  tube  the  outflow  soft-rubber  tubing  is  fastened. 
This  last  must  be  pinched,  as  it  is  the  larger,  in  order  that  fluid  may  pass 
up  the  bowel.  By  alternately  pinching  the  inflow  and  outflow  the  quantity 
of  fluid  may  be  regulated. 


MECHANICAL    PROCEDURES 


557 


The  height^  of  the  douche  bag  should  be  3  to  5  feet  above  the  patient. 

Precautions  before  insertion  of  the  tube:  The  rectum  should  always 
he  examined  digitally  before  a  hard  instrument  is  introduced,  (i)  Allow 
the  irrigating  fluid  to  flow  from  the  tube,  so  as  to  force  out  all  air  and  then 
check  the  flow.  (2)  As  the  tip  of  the  instrument  passes  through  the 
sphincter  into  the  bowel,  it  is  well  to  start  the  iflow,  so  as  to  force  the 


Fig.  270. — Kemp's    rectal 
All  metal  tube. 


irrigator.  Fig.  271. — Electric  attachment  for  electro- 

enteroclysis.     Hard-rubber    tube    with    metal 
center. 


mucosa  away  from  the  irrigator  and  fenestrae.  Also  the  entrance  of  the 
tube  is  not  interfered  with  by  the  resistance  of  the  mucous  membrane.  - 
Insertion  of  the  instrument:  The  tube  should  be  well  lubricated 
and  inserted  with  a  gentle  rotary  movement,  the  tip  directed  slightly 
back  toward  the  sacrum  and  not  forced  in;  this  is  especially  the  case  with 
the  hard  tubes.     Forcing  the  tube  in  might  injure  the  mucosa.     Do  not 


Fig.  272. 


-Kemp's   tube    (ready   for   cleansing).     Hard   rubber    with    metal    center. 
Three  sizes. 


press  the  tip  of  the  tube  against  the  wall  of  the  bowel  or  direct  the  current 
against  it,  as  either  is  irritating. 

(3)  If  the  flow  ceases,  rotate  the  tube  slightly  or  withdraw  it  slightly 
while  rotating  and  push  it  back.  If  the  return  tube  seems  plugged,  attach 
the  fountain  syringe  to  it  for  an  instant,  and  force  the  current  in  the 
opposite  direction. 

^  Modern  Methods  of  Intestinal  Irrigation,  The  Medical  Brief,  Dec,  1910;  also 
Manual  on  Enteroclysis. 


558 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


The  best  method  to  clear  the  outflow  tube  is  as  follows:  A  small 
soft  or  hard,-rubber,  or  glass  rectal  syringe  (enema)  which  contains  from 
}4  to  2  ounces  can  be  employed.  Shut  off  the  entering  current  and  then 
force  water  back  into  the  bowel  through  the  outflow  tube.  This  will 
free  it  from  the  obstruction. 

Length  of  insertion  of  the  irrigator:  The  rectal  tube  should  be  in- 
serted one- third  to  one-half  its  length  in  prostatic  cases,  etc.,  and  full 
length  for  high  irrigation. 

If  there  is  pain  or  difficulty  in  inserting  the  tube,  a  rectal  examination 
should  be  made  to  see  if  there  is  any  obstruction,  such  as  an  enlarged 


Fig.  273. — Enteroclysis    (double    current).     Patient   in    dorsal    position   on    bed-pan. 


prostate,  uterine  fibroids,  hemorrhoids,  etc.  This  examination,  should 
preferably  be  made  before  inserting  the  tube. 

Withdrawal  of  the  instrument:  Do  not  withdraw  the  tube  like  an 
ordinary  tip,  as  the  mucosa  might  catch  in  the  fenestrae.  Withdraw  it 
gently,  and  while  doing  so  rotate  it  sUghtly  first  in  one  direction  and  then 
in  the  other.  This  prevents  any  such  accident  and  frees  the  tube  if  it 
occurs. 

Cleansing  the  irrigator:  Unscrew  the  cap  and  withdraw  the  central 
tube. 

Position  of  the  Patient. — Elevation  of  the  hips  is  the  important  feature, 


MECHANICAL    PROCEDURES  559 

not  the  length  of  the  tube.  The  different  positions  of  the  patients  are 
illustrated  and  are  readily  understood  (Figs.  273-277). 

Method  by  Rotation. — Patient  is  placed  on  the  left  side  with  the 
hips  elevated,  and  the  descending  colon  is  irrigated. 

Rotate  the  patient  gradually  to  the  dorsal  position,  and  then  to  the 
right  side,  with  the  hips  elevated,  the  return  tube  being  pinched.  About 
lyi  pints  to  I  quart  (750-1000  c.c.)  of  fluid  are  allowed  to  run  into  the 
bowel. 


Fig.   274. — Enteroclysis    (double   current).     Patient    in    Sims'    position. 

The  shoulders  are  then  elevated  to  above  the  level  of  the  hips,  the 
patient  being  still  on  the  right  side.  This  is  to  make  the  fluid  gravitate 
into  the  caput  coli. 

The  shoulders  are  then  depressed  to  below  the  hip  level,  the  patient 
on  the  right  side;  he  is  then  gradually  rotated  to  the  dorsal  position  and 
then  to  the  left  side,  and  as  a  final  step  the  shoulders  are  elevated,  etc. 
In  other  words,  the  process  is  reversed.  The  return  tube  is  then  released 
and  the  fluid  is  allowed  to  escape. 

Douglas  H.  Stewart  of  New  York  has  devised  an  ingenious  and  con- 


56o 


DISEASES    OF    THE    STOMACH    AND   INTESTINES 


venient  method.  For  continuous  irrigation,  he  partly  fills  a  wash-boiler 
with  normal  salt  solution  at  the  desired  temperature,  and  this  is  kept  hot 
by  the  addition  of  fresh  hot  saline  solution;  he  hangs  a  gallon  fountain 
syringe  about  6  or  7  feet  above  the  patient.  He  employs  a  hand-pump 
to  force  the  solution  from  the  wash-boiler  through  a  connecting  tube  to 
the  fountain  syringe  above.  This  simplifies  the  entire  procedure  and  one 
does  not  have  to  disturb  the  bag  in  order  to  refill  it.  In  addition,  the 
outflow  tube  of  the  irrigator  is  left  open,  as  there  is  sufficient  force  on 


Fig.   275.— Enteroclysis  (double  current)  without  the  bed-pan. 


account  of  the  height  of  the  bag  to  carry  the  fluid  well  up  the  intestines 
Distention  is  carefully  watched  for  and  the  entering  current  shut  off  in 
such  event.  The  author  has  had  this  method  employed  on  himself  with 
excellent  results. 

I  employ  most  frequently  the  dorsal  position  without  the  bed-pan. 

Temperature  of  the  solution  depends  upon  the  conditions  of  its  em- 
ployment, an  average  of  101°  to  io5°F.  in  intestinal  catarrh;  at  iio°F. 
in  typhoid  for  an  additional  eliminative  effect,  and  for  shock  and  uremia 
at  115°  to  i2o°F.     In  the  latter  conditions  continuous  enteroclysis  may 


MECHANICAL   PROCEDURES 


561 


be  kept  up  for  one-half  to  one  hour,  about  ^i  to  i  pint  of  hot  saline  solution 
being  kept  in  the  bowel  continuously. 

Solutions  Employed. — Flaxseed  tea  (2  drams — 8.0 — of  flaxseed  to  i 
quart — liter — of  water,  boiled  twenty  to  thirty  minutes  and  strained). 
Temperature,  101°  to  i03°F.  This  should  be  rather  thin  and  oily  in 
order  to  flow  easily  from  a  fountain  syringe.  Dilute  it  with  boiled  water 
if  too  thick.  Normal  saline  solution  with  oil  of  peppermint,  5  to  15 
minims  (0.296-0.88  c.c),  or  oil  of  cinnamon,  5  to  15  minims  (0.296-0.88), 


Fig.  276. — Enteroclysis    (double   current).     Patient   in   semi-oblique   position,   as   in 
pulmonary  edema,  etc.,  when  dorsal  position  is  impossible. 


to  I  pint  (500  c.c).  Listerin,  borolyptol,  glycothymolin,  borax,  boric 
acid,  bicarbonate  of  soda,  tannic  acid,  tannin,  and  alum  have  been  em- 
ployed at  a  strength  of  i  dram  (4.0)  to  i  quart  (liter),  and  gomenol,  15 
to  20  minims  (0.88-0.00)  to  i  quart  (liter).  Gum  arable  solution,  and 
slippery-elm  solution  are  also  excellent  for  irritation.  Acetozone  or 
alphazone  i-iooo;  peroxid  hydrogen  5ii  to  the  liter;  protargol  or  argyrol 
1-2500  to  i-iooo;  quinine  i-iooo  to  1-500  are  useful  in  appropriate 
cases. 
36 


562 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Solutions  of  nitrate  of  silver,  15  grains  to  >^  dram  (1.0-2.0)  to  the 
quart  (liter),  have  been  used  in  chronic  dysentery.  Permanganate  of 
potash,  2  to  5  grains  to  1  quart  of  water,  is  valuable,  when  there  is  foul 
odor   or    much   fermentation.     Douglas   H.    Stewart    recommends    the 


Fig.   277. — Enteroclysis  (double  current).     Self-irrigation  of  the  prostate  per  rectum 

following   when    there   are   foul   odor,   fermentation,   putrefaction,   and 
excessive  bacteria: 

Chlorinated  lime 2  teaspoons; 

Commercial  acetic  acid i  tablespoon. 

Dissolve  in  i  quart  of  water. 

Then  add  9  quarts  of  plain  sterile  water.  Salt  is  incompatible  with 
acetic  acid.  Requisite  portion  of  the  10  quarts  is  used  for  irrigation. 
The  solution  eliminates  chlorin  and  yet  does  not  seem  to  irritate.  If 
salt  solution  is  desirable,  omit  the  acetic  acid  and  substitute  2  teaspoonfuls 
of  commercial  sulphuric  acid  thus: 

Commercial  sulphuric  acid 5iJ(8.o); 

Chlorinated  lime 3  J  (4-o)  > 

Normal  salt  solution 10  quarts  (liters). 

Delafield  has  used  bichlorid  of  mercury  (i  :  10,000),  2  quarts  (liters), 
for  septic  membranous  colitis  complicating  typhoid  fever,  with  a  re- 
current tube,  with  success.     Special  solutions  are  described  appropriately, 


MECHANICAL   PROCEDURES 


563 


Normal  saline  solution,  i  dram  (4.0)  of  salt  to  i  pint  (500  c.c.)  of  water, 
has  a  wide  field  of  usefulness. 

Enemata  and  enteroclysis  are  of  value  in  dysentery,  intestinal  hemor- 
rhage,^ intestinal  catarrh,  typhoid,  intestinal  colic,  tympanites,  intestinal 
toxemias,  apoplexy,  intestinal  dyspepsia,  diarrhea,  thirst,  constipation, 
impaction,  intestinal  paresis,  and  jaundice. 

They  are  extremely  useful  in  shock,  oliguria,  uremia,  sepsis,  renal  colic, 
and  in  inflammatory  conditions  of  the  genito-urinary  organs  of  both 
sexes.  The  high  enema  is  at  times  of  value  to  reduce 
intussusception. 

Irrigation  may  also  be  cautiously  employed  with 
cool  saline  solution  at  90°  to  5o°F.  to  aid  in  the  reduc- 
tion of  temperature.  There  is  an  element  of  danger  in 
the  prolonged  use  of  very  cold  water  for  this  purpose, 
shock  or  urinary  suppression  being  possible  in  asthenic 
cases. 

Proctoclysis. — In  conclusion,  I  wish  to  refer  to 
proctoclysis,  the  injection  of  normal  saline  solution 
into  the  rectum  by  the  drop  method,  as  first  suggested 
by  Dr.  John  B.  Murphy  of  Chicago.  This  procedure 
is  of  special  value  in  sepsis,  and  is  of  use  as  an  adjunct 
to  other  treatment  in  postoperative  shock,  intestinal 
paresis,  hemorrhage,  to  prevent  post-operative  thirst 
or  to  treat  it,  also  for  uremia.  In  my  experience  the 
employment  of  continuous  (recurrent)  irrigation,  with 
a  temperature  of  the  saline  solution  at  i20°F.,  is  more 
efficacious  in  shock,  intestinal  paresis  and  uremia,  fol- 
lowed by  proctoclysis  as  an  adjunct.  Rectal  feeding 
can  also  be  administered  by  the  drop  method  (procto- 
clysis) and  also  calcium  lactate  for  hemorrhage,  when 
it  cannot  be  retained  by  mouth. 

One  of  the  difiiculties  which  the  physician  must 
endeavor  to  overcome  in  the  administration  of  saline 
solution  by  the  rectum  or  by  infusion  is  the  mainte- 
nance of  a  constant  temperature  of  the  solution.  El- 
brecht's  apparatus  necessitates  a  special  heating  chamber  in  addition  to 
the  containing  reservoir,  with  the  employment  of  an  electric  heater,  an 
alcohol  lamp,  or  a  Bunsen  burner.  The  method,  though  scientific,  seems 
complicated  and  is  quite  expensive.  There  are  many  other  devices.  One 
can  use  a  fountain  syringe  of  hot  saline  solution  in  which  is  placed  a  hot 
electrc-light  bulb,  hot  towels  being  wrapped  around  the  conducting  tube. 

I  have  for  some  time  employed  the  vacuum  bottle^  with  a  specially 
devised  attachment,  which  has  proved  efficacious  in  preserving  the 
saline  solution  at  a  constant  temperature.  It  is  readily  understood. 
The  original  instrument  has  been  improved  by  placing  the  flatus  tube  high 
up.     It  is  readily  understood  from  the  illustration  (Fig.  278).     The  writer 

'  This  refers  to  hemorrhage  in  the  large  intestine,  where  an  extremely  hot  or  cold 
astringent  enema  is  of  service. 

*  New  York  Med.  Jour,  and  Philadelphia  Med.  Jour.,  Aug.  14,  1909. 


Fig.  278. — Proc- 
toclysis bottle  (heat- 
retaining). 


564  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

was  the  originator  of  the  vacuum  bottle  method  of  protoclysis.  All  the 
other  instruments  were  reported  later  than  his  own. 

Through  the  screw  cap  (B),  which  closes  the  bottle  (A),  passes  a  small 
hard-rubber  conducting  tube,  to  which  is  attached  the  outflow  tube 
(F).  Parallel  with  this  is  the  filiform  tube  (C),  which  allows  the  entrance 
of  a  fine  column  of  air,  so  as  to  render  the  flow  possible.  This  last  tube 
passes  through  the  solution  to  within  about  }i  inch  from  the  bottom  of 
the  bottle.  As  the  instrument  is  employed  inverted,  it  would  correspond 
to  the  same  distance  from  the  top  of  the  bottle.  This  filiform  tube  is 
of  hard  rubber  externally  where  exposed  to  the  air  as  a  non-conductor  of 
heat.  The  part  lying  within  the  bottle  is  purposely  made  of  metal,  so 
that  it  is  rapidly  heated  by  the  surrounding  solution,  and  the  entering  air 
is  thus,  in  turn,  heated  markedly. 

A  series  of  experiments  have  demonstrated  that  there  is  only  a  loss 
of  1°  to  2°F.  in  the  temperature  of  the  solution  in  the  bottle  during  the 
administration  of  proctoclysis  (the  drop  method)  lasting  half  an  hour, 
a  negligible  amount.  The  screw  compression  valve  (D)  is  applied  close 
to  the  bottle  attachment,  so  as  to  avoid  as  much  as  possible  the  solution 
cooling  in  the  soft  outflow  tube.  At  (£)  is  a  stopcock  with  branch  tube 
to  allow  escape  of  gas  from  rectum — a  flatus  tube.  This  outflow  tube 
(F)  is  joined  to  the  catheter  (H)  by  a  short  piece  of  glass  tubing  (G),  for 
the  purpose  of  observing  whether  the  flow  is  constant.  The  catheter  for 
rectal  injection  passes  through  a  self -retaining  rectal  tip  (/),  and  the  former 
can  be  inserted  to  any  length  desired.  The  conducting  tube  F  is  especially 
thick,  as  in  Elbrecht's  apparatus. 

An  asbestos  tube  surrounds  the  conducting  tube  from  its  junction 
at  the  bottle  to  the  catheter.  This  lessens  dissipation  of  heat  and  ob- 
viates the  use  of  hot  towels.  The  asbestos  wrapping  can  be  occasionally 
slipped  off  the  glass  connecting  joint,  so  as  to  observe  the  flow.  The 
vacuum  bottle  is  filled  in  the  usual  manner  and  the  special  cap  with  at- 
tachment screwed  on.  The  bottle  is  then  inverted  and  suspended  in  a 
cord  sling,  as  in  the  illustration.  A  small  amount  of  fluid  will  escape  from 
the  bottle  by  the  filiform  air  tube  until  the  solution  reaches  the  level  of 
the  tube,  which  now  lies  near  the  top  of  the  bottle.  The  bottle  is  then 
suspended  about  6  inches  above  the  rectum  or  higher  if  desired,  and  the 
flow  tested  for  the  proper  speed  before  inserting  the  rectal  tip  and  catheter. 

Formerly  if  flatus  occurred,  one  lowered  the  reservoir  for  a  brief  period 
to  below  the  level  of  the  abdomen,  so  the  gas  may  escape  into  the  bottle. 
At  times,  however,  it  was  necessary  to  remove  the  tube  for  a  short  period. 
The  writer  formerly  inserted  a  T-tube  between  the  reservoir  and  rectal 
catheter  to  allow  escape  of  gas.  A  short  piece  of  rubber  tubing  was  at- 
tached to  the  branch  and  immediately  clamped.  On  occurrence  of 
flatus,  the  lateral  clamp  is  removed  and  the  gas  allowed  to  escape.  It  is 
then  reclamped.  This  obviates  removal  of  the  tube.  These  procedures 
are  no  longer  necessary  with  the  newer  instrument.  As  already  stated, 
there  is  practically  no  loss  of  heat  in  the  container,  all  of  it  occurring  during 
the  passage  of  the  drops  through  the  outflow  tube;  the  slower  the  speed, 
the  greater  the  loss. 

At  the  start  the  speed  is  always  more  rapid,  and,  though  gauged  to, 


MECHANICAL   PROCEDURES  565 

say,  15  drops  per  minute,  may,  in  the  course  of  two  minutes,  drop  to  5. 
A  test  of  two  to  three  minutes  should,  therefore,  be  made  before  inserting 
the  catheter,  so  as  to  insure  a  constant  flow  at  the  desired  rate.  The  fol- 
lowing table  will  be  found  of  service;  with 


Temperature  of  ' 

water 

Length  of  tube 

Number  of  drops 

Temperature  in 

in  bottle 

(inches) 

per  minute 

rectum 

i90°F. 

30 

60 

H5°F. 

iGoT. 

30 

20  or  less 

ioo°F. 

iSO°F. 

30 

40  to  50 

ioo°F. 

138°  to  140 

°F. 

30 

150  to  200 

105°  to  iio°F. 

If  the  injection  is  given  at  a  greater  speed  than  200  drops  per  minute, 
the  solution  in  the  bottle  should  not  be  over  i2o°F.,  as  there  is  practically 
no  loss  of  temperature.  Sixty  drops  to  the  minute  is  the  speed  usually 
employed.  This  method  by  enema  or  recurrent  enteroclysis  would  be  of 
great  value  in  shock.  It  could  then  be  followed  by  proctoclysis  as  an 
adjunct. 

Hypodermodysis. — There  is  a  loss  of  10°  to  2o°F.  during  the  injection, 
depending  upon  the  size  of  the  hypodermic  needle. 

Infusion. — Dawbarn  advocates  a  temperature  of  115°  to  i20°F., 
preferably  the  latter;  time,  ten  minutes  to  the  liter  (quart). 

With  the  small  vacuum  bottle,  containing  about  i  quart  (liter), 
a  glass  V  tube  can  be  inserted  between  the  conducting  tube  and  the 


Fig.  279. — Turck's  double-current  needle  douche  for  the  sigmoid. 

rubber  tube  for  attachment  to  the  infusion  canula.  By  this  means 
it  is  possible  to  tell  when  the  bottle  is  empty  and  thus  prevent  thel  entrance 
of  air.  A  clamp  can  be  applied  close  to  the  Y  tube  on  the  canula  side 
and  the  bottle  refilled,  the  V  tube  being  refilled  before  the  conducting 
tube  is  reattached,  and  the  latter  being  done  while  the  solution  is  flowing. 

A  larger  bottle  can  be  secured  for  infusion,  but  the  smaller  one  can 
be  employed  with  these  precautions. 

The  temperature  of  the  saline  solution  does  not  practically  change 
during  the  infusion,  and  should  be  at  115°  to  i20°F.  in  the  reservoir. 

Needle  Douche;  Nebulizer;  Colonic  Massage  Bags;  Gjrromele. — 
These  instruments^  have  been  devised  by  F.  B.  Tiirck.  The  colon  needle 
douche  (Fig.  279)  I  believe  of  some  value  for  local  treatment  by  the 
alternate  hot  and  cold  spray  in  the  atonic  type  of  constipation. 

The  nebulizer  (Fig.  280)  is  recommended  by  its  inventor  for  spraying 
oils  of  cloves  or  cinnamon  into  the  colon  for  their  antiseptic,  analgesic, 
and  vasomotor  effect. 

He  recommends  distensible  bags  for  massage  of  the  atonic  sigmoid 
and  rectum,  which  I  do  not  advocate. 

The  gyromele,  already  described,  Tiirck  recommends  in  the  rectum 
and  sigmoid  for  cleansing  the  mucosa  and  producing  vibratory  movements. 

'  Journal  A.  M.  A.,  May,  1895. 


566  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

I  question  the  possibility  of  its  entering  into  the  sigmoid  flexure  except 
on  rare  occasions. 

Massage,  Gymnastics,  and  Exercise. — The  general  methods  of 
massage  have  been  described.  The  course  of  the  colon  should  be  followed. 
The  cannon-ball  and  vibratory  massage  are  of  service.  The  portable 
Vedee  vibrator  is  a  useful  instrument  for  the  general  practitioner.  It  is 
illustrated  in  Part  II  of  this  volume.  The  modern  electric  vibrators 
are  preferable.  Gymnastic  exercises  and  out-of-door  sports  are  valuable 
for  strengthening  the  abdominal  and  intestinal  musculature,  especially 
in  intestinal  atony  with  constipation.  Rowing  with  a  sliding  seat,  golf, 
horseback-riding,  bicycling,  and  walking  are  useful. 


Fig.  280. — ^Tiirck's  nebulizer. 

Mechanical  Support. — Adhesive  strapping  (Rose's  belt),  abdominal 
supporters,  etc.,  are  indicated  in  enteroptosis,  in  atonic  conditions  of  the 
intestines,  or  of  the  musculature  of  the  abdominal  wall,  in  hernial  pro- 
trusions, etc. 

Hydrotherapy. — ^The  Priessnitz  compress,  poultices,  and  the  appli- 
cation of  heat  or  cold  locally  are  useful  for  pain. 

Sitz-baths^  and  abdominal  douches  are  employed  as  already  described. 

Electricity. — Galvanic,  faradic,  and  static  electricity  may  be  employed 
percutaneously.  The  faradic,  chiefly  in  atonic  conditions;  the  galvanic, 
in  painful  neurotic  affections.  Static  electricity  can  be  used  for  both 
purposes. 

About  ten  to  fifteen  minutes  is  the  average  period  of  treatment. 
When  externally  applied  the  current  should  follow  the  course  of  the  colon 
and  then  be  given  over  the  small  intestine.  Electric  vibration  may  be 
used. 

Violet  rays,  the  high-frequency  current,  etc.,  have  been  advocated 
for  various  conditions.  The  application  of  heat  and  light  (electric-light 
bath)  to  the  abdomen  in  painful  conditions  due  to  a  gouty  or  rheumatic 

^  The  artificial  Nauheim  bath  (Triton  Salts)  is  useful  in  intestinal  atony,  or  mucous 
colic  with  sensitive  abdominal  points,  and  with  poor  circulation. 


MECHANICAL   PROCEDURES  567 

tendency,  or  in  enteroptosis,  or  mucous  colic,  its  application  to  the  sensi- 
tive areas  may  prove  of  service. 

Intrarectal  Electricity. — Boudet's  electrode  presents  the  disadvantage 
that  sometimes  frequent  evacuations  necessitate  withdrawal  of  the 
electrode. 

The  author's  instrument  (Fig.  271)  depicted  under  "Enteroclysis" 
consists  of  a  recurrent  irrigator,  external  tube,  hard  rubber  internal  tube 
metal,  with  an  attachment  for  a  battery  pole;  a  sponge  attached  to  the 
other  pole  is  placed  over  the  abdomen.  Continuous  enteroclysis  is  given 
with  hot  normal  saline  solution,  the  water  carrying  the  current. 

The  treatment  should  be  given  for  five  to  thirty  minutes,  depending 
on  the  indications.  It  is  excellent  for  simple  atonic  constipation  and 
for  intestinal  paresis.  The  faradic  current  is  preferable,  as  strong  as  the 
patient  can  bear.  The  galvanic  may  be  employed,  with  negative  pole  in 
the  rectum,  with  a  current  of  lo  to  15  milliamperes. 


CHAPTER  XXI 

DIET;  INTESTINAL  DYSPEPSIA;  CHRONIC  INTESTINAL  PUTRE- 
FACTION (INDOLIC  TYPE);  INDICANURIA;  SACCHARO- 
BUTYRIC  PUTREFACTION;  SUBINFECTION ;  PROTEIN  AB- 
SORPTION; BOTULISM;  HYDROGEN  SULPHID  AUTO- 
INTOXICATION; ENTEROGENIC  CYANOSIS;  METEOR- 
ISM;  ENTERALGIA;  VISCERAL  ARTERIOSCLEROSIS; 
SENILE  DYSPEPSIA;  ANOMALIES;  INTESTINAL  SAND 

DIET 

The  general  principles  of  diet  were  described  in  Diseases  of  the 
Stomach.     I  will  briefly  mention  a  few  rules  which  should  be  applied. 

Acuie  intestinal  disorders  must  be  managed  on  the  principle  of  rest. 
Light  food  (chiefly  liquid)  should  be  given,  such  as  broths,  barley-water, 
gruels,  koumiss,  matzoon,  bacillac  fermillac,  lactone-buttermilk,  and  in 
some  cases  milk,  but  diluted  with  barley-water  or  lime-water.  It  has  been 
demonstrated  that  in  the  acute  intestinal  catarrh  of  infants  and  children, 
undiluted  (or  at  times  even  diluted)  milk  will  frequently  pass  undigested 
and  intensify  the  inflammatory  process,  so  that  reliance  is  placed  for  a 
time  on  barley-water  and  similar  preparations. 

Seibert  has  shown  conclusively  that  milk  is  not  the  ideal  food  for 
typhoid  fever. 

In  chronic  intestinal  disease,  for  a  brief  period,  rest  may  be  given  to 
the  intestines  by  means  of  a  fluid  diet,  but  feeding  should  soon  be  increased, 
the  general  nutrition  improved,  and  the  intestinal  tract  gradually  accus- 
tomed to  a  regular  diet,  if  such  be  possible.  Milk,  cream,  raw  eggs,  car- 
bohydrates, and  fats  (butter)  are  of  value  to  improve  nutrition. 

In  these  chronic  cases  especially,  and  also  in  intestinal  dyspepsia,  all 
or  some  special  digestive  function  may  be  disturbed,  such  as  for  proteins, 
fats,  or  carbohydrates.  The  presence  of  indicanuria,  the  test-diet  with 
stool  examination,  the  fermentation  test,  together  with  the  clinical  symp- 
toms, will  determine  the  type  of  disturbance  of  the  intestinal  digestive 
function.     The  findings  would  modify  the  diet. 

Dietetic  measures  are  of  special  value  in  reference  to  disturbances 
accompanied  by  constipation  or  diarrhea. 

I.  Laxative  foods  are  articles  which  increase  intestinal  peristalsis. 
Among  such  are  fruit  juices  and  raw  and  cooked  fruits,  such  as  apples, 
pears,  plums,  peaches,  strawberries,  gooseberries,  dates,  and  figs.  Salads, 
garden  vegetables,  due  to  water  contained  and  indigestible  residue,  such 
as  melons,  cucumbers,  spinach,  tomatoes,  pumpkins,  and  cabbage;  cider; 
bonny-clabber,  koumiss,  matzoon,  and  bacillac,  fermillac  through  formation 
of  acid  products  and  gas,  increase  peristalsis.  Some  of  the  fruits  and 
vegetables  mentioned  have  a  similar  effect.     Brown  bread  and  oatmeal 

S68 


DIET  569 

tend  to  move  the  bowels,  also  water  or  carbonated  waters.  Sugar  has  a 
laxative  effect.  Considerable  fat,  in  the  form  of  cream,  butter,  or  olive 
oil,  aids  bowel  action. 

2.  Constipating  Foods. — Among  such  are  substances  containing 
astringent  agents,  especially  tannic  acid,  such  as  tea,  dried  bilberries, 
French  red  wines,  cocoa,  the  acorn  preparations,  such  as  acorn  coffee,  acorn 
cocoa;  mucilaginous  foods,  such  as  sago,  tapioca,  rice,  and  barley;  also 
foods  which  leave  little  residue  and  exert  no  irritation,  such  as  albu- 
min-water (white  of  egg  dissolved  in  water),  scraped  raw  beef,  mutton 
broth,  etc. 

Pathologically,  excess  of  carbohydrates  may  be  a  cause  of  diarrhea,  as 
may  excess  of  proteins. 

Milk  is  constipating  in  one  person,  laxative  in  another,  and  has  no 
special  effect  on  others.     Boiled  milk  is  usually  constipating. 

Dietetics  have  changed  markedly  during  the  last  few  years.  In 
chronic  colitis  with  diarrhea  the  chief  diet  was  formerly  scraped  meat. 
Modern  methods  allow  a  much  greater  variety,  and  the  employment  of 
mashed  potatoes  and  boiled  rice  lessen  peristalsis  and  are  often  of  con- 
siderable value. 

Certain  foods,  when  taken  under  ordinary  conditions,  have  no  marked 
influence  in  increasing  peristalsis;  among  these  are  meats,  fish,  meat 
powders,  artificial  foods,  such  as  peptone,  nutrose,  somatose,  plain  or 
flavored;  eggs,  well-baked  bread  (wheat),  crackers,  zwieback,  and  butter 
or  fat  in  small  amount. 

Marked  seasoning  of  foods  increases  peristalsis.  The  finer  the  particles 
of  food,  the  less  the  irritation;  the  coarser  they  are,  the  greater  stimula- 
tion they  produce  on  the  intestines. 

Gelatin. — I  have  referred  to  the  value  of  gelatin  in  ulcer  of  the  stomach 
and  in  hyperchlorhydria.  Gelatin  does  not  built  up  new  tissue,  no  matter 
how  much  is  ingested,  though  it  may  diminish  tissue  waste  (Voit).^  It 
cannot  be  reconverted  into  a  protein. 

Kirshmann^  shows  that  gelatin  spares  protein  in  metabolism. 

The  ingestion  of  7.5  per  cent,  of  the  total  heat  requirement  of  the 
organism  in  the  form  of  gelatin  spares  23  per  cent,  of  the  body's  protein, 
while  60  per  cent,  gelatin  reduces  it  35  per  cent.  One  gram  of  gelatin 
furnishes  4.1  calories.  About  50  grams  of  gelatin  represents  this  require- 
ment in  a  person  weighing  154  pounds.  The  small  amount  of  gelatin  has 
nearly  as  much  effect  as  larger  quantities.  Its  value  in  typhoid  is,  there- 
fore, evident  to  lessen  nitrogen  excretion. 

Kaufmann^  shows  that  when  the  lacking  tryosin,  cystein,  and  trypto- 
phan are  mixed  with  gelatin  in  the  proportion  in  which  they  occur  in  true 
protein,  and  are  given  to  a  dog  or  man,  nitrogen  equilibrium  may  be 
established. 

Gelatin  does  not  yield  indol,  and  can  be  employed  in  the  form  of  jellies 

as  a  nitrogenous  substance  to  replace  proteins  in  cases  of  indicanuria 

(Herter)." 

'  Hermann's  Handbuch,  Stoffwechsel,  1881,  p.  396. 

2  Zeitschrift  fur  Biologic,  1900,  Bd.  xl,  p.  54. 

'  Pfliiger's  Archiv,  1905,  Bd.  clx.,  p.  440. 

*  Bacterial  Infections  of  the  Digestive  Tract,  p.  267. 


570  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

In  severe  inflammation  of  the  intestines  artificial  feeding  may  be 
necessary,  by  rectum  or  subcutaneously. 

Rectal  alimentation  has  been  described  under  Diet,  in  Part  II. 

Sterile  olive  oil,  i  to  2  ounces  (30.0-60.0),  may  be  injected  subcu- 
taneously two  or  three  times  a  day  between  the  crest  of  the  ileum  and 
lower  border  of  the  ribs  (preferably).  Sterile  almond  oil  in  doses  of  i 
to  2  drams  (4.0-8.0)  may  be  substituted.  I  do  not  advocate,  however, 
the  subcutaneous  method. 

Normal  saline  solution,  i  pint  (500  c.c.)  to  i  quart  (liter),  may  be 
slowly  injected  in  the  same  region  in  case  of  collapse  or  hemorrhage. 

INTESTINAL    DYSPEPSIA 

With  intestinal  catarrh,  or  biliary  or  pancreatic  obstruction,  there  is 
perversion  of  intestinal  digestion.  These  conditions  will  not  be  considered 
here. 

Digestive  processes  in  the  intestine  may  become  abnormal  when  the 
intestinal  contents  are  no  longer  normal.  This  may  occur  even  with 
intact  mucosa  and  with  sufficient  bile  and  pancreatic  juice.  Indigestible 
food,  or  excess  in  some  special  types  of  food,  may  lead  to  fermentative  or 
putrefactive  processes  in  which  bacteria  take  part,  and  may  produce 
dyspeptic  symptoms. 

Indicanuria  or  saccharobutyric  putrefaction  occur  from  these 
conditions. 

There  may  be  functional  disturbances  of  pancreatic  digestion  for 
the  proteins,  carbohydrates,  and  fats,  or  any  one  or  two  of  these  functions 
may  be  disturbed. 

Riegel  describes  cases  with  marked  fermentation  of  the  carbohydrates. 
There  is  a  jejunal  diarrhea  of  gelatinous  semifluid  character,  often  quite 
green,  with  bile-pigment  reaction  and  acidity.  There  is  mucus  in  these 
movements,  but  no  formed  elements,  such  as  epithelial  and  round  cells, 
which  occur  in  catarrhal  conditions.     Catarrh  may  ultimately  result. 

Herter^  shows  that  there  is  an  intestinal  indigestion  in  children  of 
marantic  type,  in  which  there  is  intolerance  to  carbohydrates,  and  light- 
colored  and  gray  or  fatty  stools  occur.  Indican  and  phenol  are  found  in 
large  amount  in  the  urine.  A  great  number  of  Gram-positive  bacilli  of 
the  Bacillus  bifidus  type  occur  in  these  cases. 

Schmidt  and  Strassburger  describe  "intestinal  fermentation"  as 
dyspepsia  in  which  the  stools  are  light  yellow,  foamy,  with  the  odor  of 
butyric  acid.  Fatigue,  discomfort,  loose  stools,  or  even  diarrhea  may 
occur.  Abdominal  pains,  distention,  and  some  tenderness  may  be 
present.  These  cases  correspond  to  saccharobutyric  putrefaction  (Herter)  .^ 
Dyspeptic  symptoms  may  be  due  to  the  decomposition  of  proteins.^ 
Various  symptoms,  as  stated,  may  be  present  with  intestinal  dyspepsia, 
such  as  distention,  pain,  borborygmi,  passage  of  flatus,  feeling  of  dis- 
comfort in  the  abdomen.  Diarrhea  or  irregularity  of  the  bowels  is  present ; 
loss  of  appetite,  eructations,  nausea,  and  even  vomiting  may  occur.     The 

1  Ibid.,  p.  285. 

2  Bacterial  Infections  of  the  Digestive  Tract,  pp.  294,  300. 
'  Ibid.,  pp.  280,  306. 


SUBINFECTION ;   PROTEIN   ABSORPTION  57 1 

best  metho4  of  determining  the  intestinal  functions  is  by  the  Schmidt- 
Strassburger  test-diet,  with  examination  of  the  stool. 

Treatment. — That  variety  of  food  must  be  limited  for  which  the  par- 
ticular disturbance  exists.  Liquid  or  semiliquid  diet  may  be  necessary. 
Indicanuria  and  saccharobutyric  putrefaction  must  be  appropriately  treated. 

Lactic  acid  has  been  recommended  in  the  form  of  fermented  milks 
such  as  koumiss,  matzoon,  bacillac,  fermillac,  kefir,  or  lactone-buttermilk; 
chicken,  jellies,  gruels,  etc.,  can  be  given  later. 

Calomel,  >io  grain  (0.0016)  four  times  a  day,  is  suggested  by  Van 
Valzah^  for  fermentation;  or  resorcin,  5  grains  (0.3)  t.i.d.,  is  excellent. 

Taka-diastase,  5  grains  (0.3)  t.i.d.,  is  valuable  in  amylaceous  dys- 
pepsia; or  pancreon,  5  grains  (0.3)  t.i.d.,  in  disturbances  of  fat  and  pro- 
tein digestion,^  and  pancreatin,  same  dosage.  Cellasin,  5  to  10  grains 
(0.3-0.6),  given  t.i.d.  an  hour  after  meals,  in  combination  with  bicar- 
bonate of  soda,  10  grains  (0.6),  has  of  late  proved  valuable  in  amylaceous 
and  fatty  dyspepsia. 

Holadin,  an  extract  of  the  entire  pancreas  gland,  represents  all  the 
constituents  of  the  gland,  both  of  the  digestive  and  internal  secretions. 
This  may  be  given  in  a  3-grain  (0.3)  capsule.  One  would  begin  with  one 
capsule  immediately  before  or  two  hours  after  each  meal,  and  increase  to 
two  capsules  t.i.d.  The  writer  usually  adds  a  tablet  of  secretin  or, 
preferably,  prosecretin,  i  grain  t.i.d.,  to  the  above  to  stimulate  pan- 
creatic secretion.  As  the  bile  salts  intensify  the  action  of  the  pancreas, 
one  may  at  times  substitute  capsules  containing  holadin  and  bile-salts 
(holadin,  2>^  grains;  bile-salts,  }4  grain  in  each  capsule).  One  of  these 
is  given  t.i.d.  about  three  hours  after  meals.  Enterokinase  in  3-grain 
(0.2)  doses  may  also  be  given.  This  product  (Fairchild's)  is  still  in  the 
experimental  stage.  A  ferment  of  the  duodenum,  it  activates  the  tryp- 
sinogen.  The  writer  usually  first  tries  holadin  with  prosecretin  and, 
lately,  the  addition  of  enterokinase. 

Ad.  Schmidt,^  Gross^  and  others  have  recommended  insufflation  of  the 
small  intestine  through  the  duodenal  tube  for  intestinal  fermentation. 
The  writer  believes  it  might  be  worthy  of  trial  in  obstinate  cases. 

In  conclusion,  I  would  advise  that  in  the  milder  cases  the  special 
food  stuff  which  causes  dyspepsia  should  be  limited  in  quantity,  but 
not  entirely  cut  off.  Eggs,  soft  boiled  or  raw,  vegetables  in  mashed 
forms,  bread  or  crackers,  stale  and  well  broken  up,  are  of  service,  butter 
or  cream  according  to  indication.    Later  the  diet  is  increased. 

SUBINFECTION;  PROTEIN  ABSORPTION;  AND  CHRONIC 
INTESTINAL  PUTREFACTION 

There  has  been  an  unfortunate  tendency  to  attribute  many  human 
ills  to  the  well-worn  term  "auto-intoxication."  Self -poisoning  properly 
speaking  is  due  to  substances  arising  within  the  organism,  to  products  of 
metabolism,  or  derivatives  of  disintegrated  or  disorganized  cells.     Adami 

^  Med.  News,  Jan.  17,  1903. 

'  True  Intestinal  Dyspepsia  (Einhorn),  Amer.  Jour,  of  Med.  Sciences,  November, 
1907;  also  Med.  Record,  September  4,  1909. 
'  Zentralblatt  f.  innere  Medicin,  191 2,  No.  i. 
*  Med.  Record,  Nov.  30,  191 2. 


572  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

justly  holds  that  products  which  arise  in  the  alimentary  tract  by  the 
action  of  invading  organisms  (from  without)  are  not  auto-intoxicants; 
for  example,  with  botulism  the  Bacillus  botulinus  has  been  isolated 
from  raw  ham  and  the  Germans  assert  that  Bacillus  paratyphosus  is  a 
habitat  of  beef  and  that  the  fever  is  produced  by  toxins  generated  by  these 
bacilli  in  ingested  beef.  In  some  cases,  apparently  originating  from  the 
intestinal  tract  in  primary  pernicious  anemia  and  secondary  anemia, 
where  there  are  pronounced  indications  of  excessive  saccharobutyric 
intestinal  putrefaction  such  as  described  by  Herter,  and  in  which  the 
intestinal  condition  was  believed  to  be  the  chief  cause,  streptococci  some- 
times of  oral  origin  have  also  been  found;  so  that  these  conditions  were  due 
to  a  combination  of  intestinal  putrefaction  and  infection  from  without 
(streptococci). 

Adami  holds  that  many  cases  of  improperly  called  auto-intoxication 
originate  not  necessarily  through  the  lower  bowel  but  are  due  to  the 
carriage  of  bacteria  through  the  mucosa  at  any  point  from  the  mouth  to 
the  anus  and  the  leukocytes  may  act  either  as  carriers  or  destroyers,  of 
these  organisms.  When  there  is  an  inflammation  in  the  alimentary 
tract,  there  is  an  increased  passage  of  leukocytes  from  the  inflamed  area, 
and  increased  carriage  of  bacteria  into  the  blood.  An  active  inflammation 
may  result  in  some  other  regions,  or  the  condition  which  Adami  terms 
"subinfection." 

In  this  last,  the  bacteria  become  destroyed  and  liberate  toxins  which 
poison  the  cells  in  their  vicinity.  Certain  cells  may  die  as  a  result  and 
be  replaced  by  fibrous  tissue.  Adami  argues  that  the  veils  of  intestinal 
stasis  described  by  Lane,  result  more  from  subinfection  and  low  forms 
of  infection  than  from  chronic  intoxication.  Experimentally,  repeated 
infection  of  colon  bacilli  during  anesthesia  on  animals  may  produce  con- 
nective-tissue formation  (cirrhosis)  of  the  liver.  Moreover  a  high  grade 
of  anemia,  closely  resembling  pernicious  anemia,  has  been  produced  in 
dogs  by  repeated  injections  of  cultures  of  colon  bacilli  of  low  virulence 
and  changes  consisting  of  diffuse  degeneration  in  the  columns  of  GoU, 
resembling  those  found  in  cases  of  pernicious  anemia  also  occur. 

This  is  another  illustration  of  Adami's  theory  of  subinfection.  We 
thus  may  have  an  apparently  pernicious  anemia,  result  from  chronic 
excessive  intestinal  putrefaction — the  B.  aerogenes  capsulatus  as  a  factor 
(Herter),  or  from  chronic  excessive  intestinal  putrefaction  plus  strepto- 
coccus infection  (oral  in  some  cases),  or  from  subinfection. 

Moreover  cases  are  reported  of  apparently  acute  articular  rheumatism 
in  whom  colon  bacilluria  was  marked,  and  cure  resulted  from  the  use  of 
autogenous  vaccines,  or  from  large  doses  of  hexamethylenamin,  an  illus- 
tration of  direct  bacterial  infection.  The  writer  on  the  other  hand  has 
had  excellent  results  in  a  case  of  rheumatoid  arthritis  following  the  use 
of  sour  milks,  lactic  acid  bacilli  and  intestinal  irrigation,  as  to  disappear- 
ance of  pain,  and  diminution  of  swelling — and  more  ready  ability  to 
move  the  joints.  There  was  no  cure,  however.  A  number  of  observers 
have  noted  improvement  after  intestinal  irrigation. 

A  second  source  of  error,  is  the  disregard  of  the  fact  that  certain  con- 
ditions may  arise  which  may  be  due  not  to  auto-intoxication  (so-called) 


CHRONIC   INTESTINAL   PUTREFACTION  573 

but  to  protein  absorption,  from  an  idiosyncrasy  which  may  particularly 
occur  with  certain  foods  in  certain  patients. 

The  Protein  Poison  (Protein  Absorption). — Vaughan  and  Wheeler 
in  1903,  found  that  the  cellular  substance  of  the  colon  bacillus^  con- 
tains a  highly  active  poison  and  that  a  closely  related  or  similar  poison 
could  be  obtained  from  other  pathogenic  and  non-pathogenic  bacteria 
and  from  vegetable  and  animal  proteins.  It  is  not  found  in  gelatin. 
The  symptoms  induced  by  this  poison  in  guinea-pigs  are  first,  peripheral 
irritation  such  an  urticarial  rash;  second  stage,  partial  paralysis  with 
rapid  and  shallow  breathing,  and  the  third  or  convulsive  stage  which 
begins  as  isolated  clonic  movements  and  finally  becomes  general,  involv- 
ing all  the  muscles  of  the  body;  with  fatal  doses  there  is  a  progressive 
fall  of  temperature.  Small  doses  administered  subcutaneously  in 
animals  produce  fever  and  various  types  of  fever  may  be  simulated 
by  varying  the  size  of  the  dose  and  the  intervals  of  administration. 
When  proteins  are  acted  on  by  the  digestive  juices,  the  product  be- 
comes poisonous  at  the  peptone  stage  and,  if  it  were  so  absorbed  into 
the  circulation,  it  would  be  highly  injurious,  but  with  normal  digestion, 
the  peptone  is  broken  up  into  harmless  amino-acids.  If  proteins,  how- 
ever, enter  the  blood  without  being  properly  changed  by  the  action  of 
the  digestive  juices,  then  they  must  be  digested  in  the  blood  and  tissues 
(parenteral  digestion)  and  during  the  process  the  protein  poison  is  set  free 
and  exerts  its  deleterious  effects  on  the  body.  It  is  suspected  by  some 
that  the  protein  has  an  influence  in  the  production  of  the  summer  diarrheas 
of  infancy,  and  studies  of  the  protein  poison  and  protein  sensitization 
have  demonstrated  how  the  protein  element  of  bacteria  influence  the 
nature  and  progress  of  the  infectious  diseases.  Special  idiosyncrasies 
to  certain  foods  may  be  explained  on  the  above-mentioned  grounds,  as 
for  example  urticaria,  presenting  the  aspect  of  anaphylaxis  from  absorp- 
tion of  protein.  In  certain  conditions  at  least  protein  absorption  with 
parenteral  digestion  is  a  cause.  Johnson  has  referred  to  its  causal  rela- 
tionship to  urticaria  and  other  skin  lesions.  An  acute  exacerbation  of 
chronic  nephritis  resulting  from  dietetic  indiscretion  may  be  the  result  of 
protein  poison  in  my  belief,  and  L.  F.  Bishop  holds  that  arteriosclerosis 
may  result  from  certain  idiosyncrasies  of  the  protein  absorption. 

Under  the  section  on  hypochlorhydria  the  author  recounts  an  interest- 
ing case  of  urticaria  with  angioneurotic  edema  attacks  which  he  believes 
due  to  protein  absorption.  Finally,  in  its  production  we  will  take  up  the 
consideration  of  chronic  intestinal  putrefaction  which  may  be  subdivided 
into  (i)  the  indolic  type,  characterized  by  the  production  of  indicanuria; 
(2)  the  saccharobutyric  type,  in  the  simple  cases  of  which  indol  is  usually 
absent;  (3)  combined  saccharobutyric  and  indolic  type,  associated  with 
excessive  production  of  indol. 

CHRONIC  INTESTINAL  PUTREFACTION 

Chronic  intestinal  putrefaction  is  in  itself  a  serious  enough  condition 
and  may  be  responsible  not  only  for  nervous  symptoms,  but  the  writer 

^  Journal  A.  M.  A.,  Nov.  15,  1913. 


574  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

believes  that  the  toxemia  therefrom  may  directly  affect  the  kidneys, 
and  be  productive  of  nephritis.  From  his  personal  observations,  it  may 
produce  high  arterial  tension  and  ultimately  arteriosclerosis  with  cardiac 
lesions.  L.  F.  Bishop  has  written  at  length  on  this  subject.  He  further 
believes  protein  absorption  may  be  a  factor, 

I.  Indolic  Type  (Indicanuria). — Indicanuria  designates  the  presence 
of  indican  in  the  urine,  as  demonstrated  by  reactions,  with  the  formation 
of  indigo,  on  using  Jaffe's,  Obermeyer's,  or  similar  tests. 

Indol  is  absorbed  from  the  intestines  and  forms  in  the  liver  indoxyl 
potassium  sulphate,  or  indican,  an  ethereal  sulphate  which  is  eliminated 
in  the  urine. 

Etiology. — There  are  various  causes  of  indicanuria:  excessive  protein 
diet,  catarrh  of  the  small  intestine  causing  alterations  in  the  mucosa  and 
increased  intestinal  putrefaction,  typhoid,  cholera,  etc.,  constipation, 
alimentary  putrefaction,  partial  or  complete  obstruction  of  the  common 
bile-duct,  decrease  of  normal  digestive  fluids,  intestinal  obstruction, 
peritonitis,  fetid  bronchitis,  tuberculosis  with  pus  cavity,  gangrene,  etc. 
Certain  drugs,  such  as  salol,  salophen,  and  creosote,  give  reactions 
which  must  not  be  mistaken  for  it,  while  hexamethylenamin  causes  its 
disappearance. 

Baar,  after  a  series  of  tests  holds  that  non-constipated  cases  show  indi- 
canuria more  frequently  than  do  the  constipated  and  believes  that  consti- 
pation has  no  bearing,  with  which  last  the  author  does  not  agree.  It  is  a 
factor  in  some  cases,  but  not  in  all.  Baar  imputes  indicanuria  to  onlv 
some  anatomic  lesion  of  the  intestinal  tract.  The  writer  agrees  so  far 
that  an  inflammatory  lesion  may  be  a  factor. 

In  cases  where  the  patients  have  increased  in  fat  from  sedentary 
pursuits,  even  in  former  athletes,  persistent  indicanuria  will  occur  during 
the  winter  months,  when  little  exercise  is  taken.  I  have  observed  this  in 
patients  who  have  normal  bowel  movements  daily.  This  condition  per- 
sists, or  recurs  in  spite  of  rigid  diet  and  treatment,  but  disappears  in 
summer  with  active  exercise.  Sedentary  life  with  fat  accumulation  and 
insufficient  exercise  (with  no  constipation)  may  therefore  produce  in- 
dicanuria as  a  result  of  disturbed  metabolism. 

One  frequently  sees  patients  complaining  of  some  diflficulty  other  than 
constipation,  when  on  close  questioning,  one  finds  normal  bowel  action 
occurs  every  other  day  or  every  third  day  or  more.  With  some  ap- 
parently healthy  persons  this  is  a  normal  condition.  They  may  have  no 
disturbing  results  from  this  habit,  no  headache,  no  nervous  symptoms 
and  no  indicanuria.  Evidently  they  do  not  absorb  indol.  There  are 
individual  peculiarities.  Yet  with  some,  constipation  is  a  marked  factor 
in  producing  indicanuria. 

Intestinal  indicanuria  is  an  evidence  of  intestinal  putrefaction.  Ex- 
cessive quantity  of  protein,  especially  of  meat,  may  be  a  cause.  Any 
condition  favoring  stagnation  in  the  intestines  helps  produce  this  condition. 
Imperfect  action  of  a  cathartic  can  produce  indicanuria. 

In  children  little  indican  appears.  Many  adults  show  indican  and 
suffer  from  no  symptoms,  but  this  is  true  of  constipation.  Finally,  persons 
^  Med.  Soc.  Greater  X.  Y.,  Mar.  i6,  1914. 


CHRONIC   INTESTINAL   PUTREFACTION  575 

with  indicanuria  show  clinical  evidences  of  intestinal  disorder  and  some- 
times symptoms  of  auto-intoxication,  frequently  affecting  the  nervous 
system.  Neurasthenic  and  even  melancholic  symptoms  may  be  dependent 
on  this  form  of  auto-intoxication.  Headache,  migraine,  myasthenia, 
epileptiform  seizures,  early  fatigue,  cyclic  vomiting,  or  progressive 
muscular  atrophy  may  also  be  dependent  on  this  condition  (Herter). 

Intestinal  putrefaction  may  directly  affect  the  liver  and  kidneys. 
I  have  a  patient  with  marked  indicanuria  with  bile  in  the  urine,  albumin 
casts,  cylindroids,  and  diminished  urea.  Treatment  of  the  intestinal 
putrefaction  cleared  up  this  condition. 

This  corroborates  the  view  of  W.  H.  Porter^  that  excessive  intestinal 
putrefaction  may  cause  disturbance  of  the  hepatic  cells.  There  was  no 
jaundice  in  this  patient.  I  further  believe  that  cirrhosis  of  the  liver 
may  result  from  chronic  intestinal  putrefaction  just  as  may  arteriosclerosis. 
From  personal  experience,  therefore,  the  author  finds  that  marked  in- 
dicanuria (intestinal  putrefaction)  may  be  directly  productive  of  aii  acute 
nephritis,  or  produce  an  acute  exacerbation  in  a  case  of  chronic  nephritis. 
This  has  been  the  experience  of  Wm.  H.  Thomson  in  a  number  of  cases 
which  he  has  reported.  Under  such  conditions,  I  would  advocate  adher- 
ence to  the  most  rigid  form  of  diet  for  the  indicanuria,  chiefly  the  sour 
milks.  After  a  practical  disappearance  of  the  indicanuria,  with  clearing  of 
the  acute  condition,  one  should  regulate  the  protein  diet  in  the  cases  of 
chronic  nephritis  according  to  this  amount  of  nitrogen  excreted  in  the 
urine.  Give  the  patient  what  he  can  take  care  of  and  no  more.  The  colon 
bacilli,  through  their  activity  in  the  decomposition  of  proteins,  are  chiefly 
responsible  for  the  production  of  indol.  The  Bacillus  aerogenes  capsulatus 
and  the  Bacillus  putrificus,  when  present,  favor  the  putrefactive  action  of 
the  colon  bacilli  on  the  proteins.^  Indicanuria,  I  believe,  further  influ- 
ences the  production  of  arteriosclerosis.  I  will  briefly  recount  an  inter- 
esting case.  The  writer  was  called  in  consultation  to  a  patient  suffering 
from  persistent  vomiting  which  apparently  could  not  be  relieved.  On 
physical  examination,  evidences  of  arteriosclerosis  and  excessively  high 
pulse  tension  were  found.  Blood-pressure  was  taken  at  once  and  found 
to  be  250.  Under  the  hypodermic  administration  of  nitroglycerin,  }4o 
grain  every  two  hours,  the  vomiting  rapidly  ceased  and  the  pressure  fell.^ 
Sodium  nitrite  was  subsequently  added  to  the  treatment.  The  urinary 
analysis  at  this  time  showed  a  very  slight  chronic  nephritis.  The  most 
interesting  feature  of  the  case  was  that  the  patient  had  during  the  course 
of  the  preceding  two  years  several  such  attacks.  Numerous  examinations 
of  the  urine  had  been  made  by  competent  pathologists,  and,  excepting 
the  excessive  indicanuria,  no  evidences  of  nephritis  had  been  found;  but 
the  high  tension  and  arteriosclerosis  were  always  present.  Numerous 
eminent  consultants  had  examined  the  patient,  and  all  agreed  that  the 
indicanuria  had  an  influence  on  the  arteriosclerosis.  The  author  believes 
the  slight  nephritis  found,  when  he  saw  the  case,  to  be  undoubtedly  of 
recent  development,  and  that  the  indicanuria  had  a  direct  bearing  on  the 
production  of  the  arteriosclerosis.     There  were  no  evidences  of  syphilis  in 

^The  Post-graduate,  Oct.,  1902. 

2  Herter,  Bacterial  Infections  of  the  Digestive  Tracti 

'Tinct.  aconite  gtts.  8  (35  per  cent,  tincture)  also  given  t.i.d. 


576  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

this  patient  and  the  Wassermann  test  was  negative.  The  treatment  of 
this  condition  would  be  the  treatment  of  indicanuria  plus  the  reduction 
of  blood-pressure  by  the  use  of  the  nitrites  and  tincture  of  aconite  (35  per 
cent,  old  Pharmacopceia),  5  to  10  drops  t.i.d.,  as  recommended  by  Wm. 
H.  Thomson,  with  the  subsequent  addition  of  the  iodid  of  soda  or  of 
potash.  In  severe  cases  of  high  pressure  the  writer  gives  in  addition  3^0 
glonoin  three  or  four  times  daily.  Occasionally  one  sees  high  pressure 
cases  in  which  large  doses  of  the  35  per  cent,  aconite,  10  drops  four 
times  daily — even  with  the  addition  of  nitroglycerin,  gr.  3^0 — four  times 
daily  will  not  cause  lessening  of  high  tension.  Tincture  veratrum  viride, 
10  to  15  drops  t.i.d.  given  in  addition  to  the  above  remedies  is  often  effect- 
ive. Recently  I  saw  in  consultation  a  case  of  apoplexy  with  a  systolic 
pressure  of  240  in  whom  all  these  remedies  failed  to  reduce  pressure. 
Venesection  was  indicated,  but  refused.  The  author  then  administered 
amyl  nitrate  by  the  drop  method  of  inhalation,  i  dram  in  half  an  hour 
with  resulting  fall  of  pressure  of  40  points.  This  was  followed  immediately 
by  aconite,  etc.,  and  the  pressure  gradually  fell  to  160  where  it  was  held 
without  difficulty.  Metchnikoff  believes  that  his  experiments  have  now 
established  beyond  question  that  small  doses  of  paracresol  and  indol, 
acting  on  the  organism  over  a  longer  or  shorter  period,  are  capable  of 
inducing  chronic  lesions  of  the  nature  of  sclerosis.  Such  lesions  are  the 
ones  that  are  most  frequently  encountered  in  senility.  He  has  demon- 
strated, he  states,  that  the  phenols  and  indol  found  in  the  urine  and  stool 
are  not  the  excreta  of  our  tissues,  but  are  the  products  of  the  permanent 
microbian  flora.  It  is  not  unreasonable  to  suppose  that  the  digestive 
tract  can  constantly  harbor  an  injurious  flora,  the  source  of  chronic  poison- 
ing leading  to  arteriosclerosis.  The  colon  bacillus  and  Bacillus  perfringens 
produce  poisons  which  are  absorbed  by  the  intestinal  walls  and  are  capable 
of  inducing  serious  lesions  in  arteries,  kidneys,  liver,  and  other  organs. 
His  observations  are  described  in  the  Annales  de  ITnstitut  Pasteur,  Paris, 
October,  1910,  xxiv.  No.  10,  pp.  753-831. 

Taylor^  recently  reports  transient  heart-block  due  to  indicanuria. 
Polyneuritis  with  vaga tonic  symptoms  and  vagotonia  have  been  imputed 
to  intestinal  putrefaction  by  von  Noorden.^ 

The  following  test  for  indican  is  reliable:  Place  in  a  test-tube  equal 
quantities  (10  c.c.  of  each)  of  urine  and  chemically  pure  concentrated 
hydrochloric  acid.  To  this  mixture  add  3  drops  of  J-^  per  cent,  solution 
of  potassium  permanganate.  Then  add  a  small  portion  of  chloroform, 
I  or  2  more  drops  of  the  permanganate  solution,  and  a  few  drops  more  of 
chloroform,  or  a  total  of  75  drops  (5  c.c.)  of  chloroform,  and  shake  vigor- 
ously for  a  few  seconds. 

Indigo-blue  is  deposited  in  presence  of  this  indicator.  Bile  should  be 
tested  for,  even  if  there  are  no  evidences  of  jaundice.  W.  H.  Porter's 
scale  (Plate  I)  is  a  basis  of  comparison  in  the  absence  of  the  bile  test. 

Rosenbach's  test,  which  consists  in  boiling  the  urine  with  nitric  acid, 
gives  a  Burgundy  red  if  putrefaction  is  present.  This  may  occur  when 
no  indican  is  found.     It  is  due  to  substances  of  a  like  class. 

1  Jour.  Amer.  Med.  Assoc,  April  18,  1908 

2  Journal  A.  M.  A.,  Jan.  11,  1913. 


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CHRONIC    INTESTINAL    PUTREFACTION  577 

Treatment. — Diet. — Matzoon,  koumiss,  lactone-buttermilk,  bacillac; 
fermillac,  later,  stale  crackers  with  butter,  boiled  rice,  grape-nuts  and  jellies 
(gelatin)  are  to  be  added.  Herter  shows  that  clinically  the  carbohydrates 
have  an  influence,  and  the  substitution  of  a  quickly  digested  carbo- 
hydrate, like  rice  which  has  been  well  cooked  and  forced  through  a 
colander  or  large  quantities  of  bread  or  sugar,  will  lessen  the  excretion 
of  indican.  Taka-diatase  or  cellasin  can  also  be  given  to  aid  their 
digestion. 

Medication. — Blue  mass,  5  grains  (0.3);  calomel,  5  grains  (0.3),  once 
a  week,  and  a  saline  cathartic  for  a  short  period  daily. 

Hexamethylenamin,  5  to  10  grains  (0.3),  with  benzoate  of  soda,  10 
grains  (0.6),  t.i.d.,  has  cleared  up  many  cases,  albumin  casts,  bile,  and 
indican  disappearing  within  a  short  time.  This  shows  the  improvement 
was  not  due  to  the  mere  interference  with  indican  reaction.  Lactic  acid 
bacilli  tablets  or  preferably  the  liquid  form  of  lactic  acid  bacilli  are  useful. 
Fairchild's  and  those  advocated  by  Metchnikoflf  have  given  me  good 
results. 

Aspirin,  salicylate  of  soda,  and  salol,  5  to  10  grains  (0.3-0.6),  are  of 
service.     The  following  have  sometimes  proved  of  value. 

I^.    Sulphocarbolate  of  soda 3iv; 

Permanganate  potass gr.  xlviij; 

Beta-naphthol gr.  xlviij. — M. 

Div.  in  capsules  No.  xlviii.     Shellac  cover. 

Sig. — One  three  times  a  day,  after  meals  and  at  bedtime. 

or, 

I^.     Sod.  glycocholate 3  i; 

Sod.  salicy gr.  Ixxv; 

Pancreatin gr.  cl; 

Sod.  bicarb gr.  cl. — M. 

Div.  in  capsules  No.  xc. 

Sig. — Two  to  three  capsules  t.i.d.,  a.c.  or  two  hours  p.c. 

Enteroclysis  is  valuable,  especially  the  injection  of  i  pint  to  i  quart 
(500-1000  CO.)  of  a  I  :  1000  acetozone  solution,  with  the  patient  in  the 
knee-chest  posture.  This  should  be  retained  for  a  short  time.  This 
procedure  can  be  carried  out  every  day  or  few  days.  Gastric  disturbances 
should  he  investigated  and  corrected. 

George  A.  Tuttle  has  shown  that  potassium  iodid,  especially  in 
cases  with  arteriosclerosis,  will  lessen  indican.  Basham's  tincture 
has  been  of  benefit  in  some.  Some  have  advocated  acetozone  solu- 
tion (i  :iooo),  I  pint  (500  c.c),  in  divided  doses  daily  by  mouth. 

Bassler^  recommends  rectal  instillations  of  autogenous  bacteria  and 
strains  of  the  colon  bacillus  in  chronic  intestinal  putrefaction,  but  the 
writer  does  not  advise  the  method.  Rectal  and  duodenal  inflation  with 
oxygen  has  been  advocated  by  Gross. ^  The  writer  is  dubious  of  its 
value.  The  author  recommends  hexamethylenamin  treatment  combined 
with  lactic  acid  bacilli,  liquid  form,  and  sour  milks,  with  enteroclysis  in 
obstinate  cases. 


^  Med.  Record,  Sept.  24,  1910. 
^  Med.  Record,  Nov.  30,  191 2. 


37 


578  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

2.  Saccharobutyric  Type  of  Intestinal  Putrefaction. — This  type  of 
decomposition  is  produced  chiefly  by  the  Bacillus  aerogenes  capsulatus/ 
Gram-positive.  Bacillus  putrificus  or  Gram-positive  diplococci  may  at 
times  be  associated. 

The  Bacillus  aerogenes  under  anaerobic  conditions  can  attack  car- 
bohydrates and  proteins.  Butyric  acid  is  often  formed  in  considerable 
amount,  carbon  dioxid,  hydrogen,  ammonia,  and  often  propionic,  caproic, 
or  valeric  acids.  The  odor  of  the  movements  is  often  intense  and  char- 
acteristic of  butyric  or  caproic  acid.  Excessive  gas  is  liberated.  The 
seat  of  this  process  is  chiefly  in  the  large  intestine  and  lower  ileum. 

When  proteins  are  attacked  there  is  less  gas  liberated.  With  ex- 
cessive gas  production  the  feces  have  a  low  specific  gravity  and  float 
on  wgiter.  There  are  small  bubbles  in  the  contents  and  the  feces  are  a 
light  color.  Patients  who  suffer  from  this  condition  do  not  tolerate 
well  either  carbohydrates  or  acids,  flatulence  and  diarrhea  occurring 
after  use  of  cereals,  starchy  food,  and  especially  sugar.  The  mucous 
membranes  of  the  digestive  tract  are  easily  irritated,  and  there  may  be 
epithelial  desquamation  in  the  mouth.  Howard^  has  described  instances 
of  superficial  necrosis  of  the  mucous  membrane  of  the  stomach  and 
intestines,  associated  with  an  abundant  presence  of  the  Bacillus  aerogenes 
capsulatus.  These  necrotic  areas  most  often  lie  beneath  the  folds  of  the 
valvulae  conniventes  and  may  occur  with  gas  cysts.  It  does  not  seem  likely 
that  these  bacilli  are  responsible  for  severe  acute  inflammatory  lesions 
of  the  intestines,  but  more  probably  for  the  subacute  enteritis  that  is  so 
often  present  in  cases  that  show  large  numbers  of  the  bacilli  in  the  stools. 
There  are,  moreover,  many  instances  of  acute  diarrhea  associated  with 
free  Bacillus  aerogenes  capsulatus  multiplication  and  with  severe  primary 
anemia,  and  in  children  capsulatus  infection  may  lead  to  the  develop- 
ment of  extreme  anemia  with  general  edema.  The  Bacillus  aerogenes 
capsulatus  is  an  active  hemolysing  agent^  and  many  instances  of  "pri- 
mary" pernicious  anemia  and  of  secondary  anemia  show  pronounced 
indications  of  excessive  saccharobutyric  putrefaction  (infection  with  the 
Bacillus  aerogenes  capsulatus),  and  probably  this  infection  has  a  causal 
relation  to  the  anemia.  Streptococci  (sometimes  of  oral  origin)  are  at 
times  found  in  some  of  these  anemias  in  addition  to  the  Bacillus  aerogenes 
capsulatus,  and  the  anemia  may  be  due  to  the  combination.  In  the 
simple  cases  indol  is  generally  absent. 

3.  Combined  Saccharobutyric  and  Indolic  Type. — The  Bacillus 
aerogenes  capsulatus  is  also  able  to  break  down  proteins  into  a  suit- 
able form  for  the  use  of  other  putrefactive  bacteria,  among  which  are 
the  indol-forming  organisms. 

This  last  form,  associated  with  the  excessive  production  of  indol, 
is  the  most  severe  type,  and  these  cases  are  subject  to  auto-intoxica- 
tion, depressive  mental  conditions,  and  diminution  in  muscular  power 
(muscle  fatigue),  according  to  Herter. 

^  Herter,  Bacterial  Infections  of  the  Digestive  Tract. 

2  Contributions  to  the  Science  of  Medicine,  dedicated  by  his  pupils  to  Wm.  Henry 
Welch  on  the  25th  anniversary  of  his  doctorate,  Baltimore,  1900,  p.  461. 

3  On  Bacterial  Processes  in  the  Intestinal  Tract  in  Some  Cases  of  Advanced  Anemia, 
etc.  (Herter),  Jour,  of  Biological  Chemistry,  vol.  II,  Nos.  i  and  2,  Aug.,  1906. 


CHRONIC   INTESTINAL   PUTREFACTION 


579 


In  the  severe  types  the  anaerobic  organisms,  especially  the  Bacillus 
aerogenes  capsulatus,  produce  hemolytic  substances  which  are  believed 
to  have  a  bearing  on  the  production  of  pernicious  anemia. 

The  results  of  intestinal  irrigation  in  such  cases  have  been  favor- 
ably reported  by  Hollis^  and  Ditman,^  as  in  Fig.  281,  with  marked  im- 
provement in  the  hemoglobin  and  red  cells. 

Arthritis  deformans^  has  recently  been  imputed  to  putrefactive 
changes  in  the  intestinal  canal.  In  one  case  excellent  results  were  secured 
by  the  author  by  enteroclysis  and  fermented  milks,  no  medication;  the 
swelling  in  the  joints  rapidly  subsiding. 


N'ov. 

l^eoeTnt>er 

January 

Kebruary 

March 

globm 

Rid  BiMd 

33  SO 

3      0       10     20 

s    10    18    ae 

1     r     13    SI 

1        7        13 

Indicftri 

Very  Strong 
Strong 

IOOH 

S,000,000 

4,S00,00O 

4,000,000 

3,800,000 

3,000.000 

2,500,000 

2,000,000 

1,300,000 

1,000,000 

300,000 

0 

V>% 

/ 

/^ 

s. 

io% 

/ 

/ 

70% 

/ 

J 

/s 

•<». 

60% 

/ 

/ 

/ 

50« 

N 

S 

^  . 
?■ 

/ 

f 

V 

Vi% 

\ 

^ 

\ 

/ 

/ 

/ 

SOSi 

A 

< 

A 

V 

^ 

V 

V, 

/ 

/ 

yoV 

/ 

\, 

V 

\ 

^ 

k 

\ 

y 

WH 

\ 

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oy. 

U^rr.r.Mr.W.r.                                                 Q^A   U\r,r.A    C ^W^       .... 



Fig.  281. — Chart  of  pernicious  anemia  demonstrating  value  of  enteroclysis. 


Treatment. — Careful  mastication  of  the  food,  cleanliness  of  the 
mouth,  and  correction  of  gastric  disturbances  are  necessary.  Sugars 
should  be  omitted,  starchy  food  cut  down,  and  meat  diminished  or 
eliminated  if  the  mixed  type  with  indican  is  present. 

Taka-diastase,  5  grains  (0.03)  t.i.d.,  aids  starch  digestion.  Pan- 
creatin  preparations  may  be  tried.  Holadin,  3  grains  (0.2),  with 
presecretin,  i  grain,  and  enterokinase,  3  grains  (0.2)  t.i.d.,  may  be 
substituted.     Pancreon,  5  grains  (0.3)  t.i.d.,  is  useful.     The  fermented 

^  Herter,  Bacterial  Infections  of  the  Digestive  Tract. 

^  Med.  Record,  Feb.  2,  1907. 

^  A  Preliminary  Report  on  the  Relation  of  Albuminous  Putrefaction  in  the  Intestines 
to  Arthritis  Deformans,  by  Andrews  and  Hoke,  American  Journal  of  Orthopedic  Surgery, 
July,  1907;  also  Cornwall,  Med.  Record,  April  i,  1911. 


580  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

milks  are  of  special  value.  Lactic  acid  bacilli  tablets  and  particularly 
the  liquid  form  are  useful. 

Enteroclysis,  or  high  enemata,  with  saline  solution,  acetozone  (i  :  1000) 
or  hydrogen  peroxid  (i  :  1000),  are  of  service.  The  latter  are  of  special 
value. 

Ichthoform,  formidin,  ichthalbin,  aspirin,  salol,  salicylate  of  soda, 
5  grains  (0.33)  t.i.d.,  are  useful,  or  urotropin,^  5  grains  (0.3),  with  benzoate 
of  soda,  10  grains  (0.6)  t.i.d.  This  last  combination,  with  the  addition 
of  the  high  enema  of  acetozone,  i  quart  (liter),  strength  i :  1000, 1  have 
found  of  great  value.  Permanganate  of  potash,  up  to  i  grain  (0.06) 
t.i.d.,  may  be  of  service.  Herter  suggests  the  possible  value  of  dioxid 
of  manganese.  Surgery  may  be  indicated  in  extreme  cases.  If  dilatation 
of  the  stomach,  not  responding  to  medical  treatment,  is  the  cause,  then 
gastro-enterostomy  is  indicated.  With  failure  of  medical  treatment 
and  progressive  anemia  and  mental  disturbances,  Herter  suggests  ap- 
pendicostomy  followed  by  enteroclysis.  I  am  opposed  to  shortening  or 
short  circuiting  the  large  intestine  for  this  condition.  In  extreme  cases 
Gant's  cecostomy,  with  irrigation  of  colon  and  ileum,  might  be  of  service. 

ACIDOSIS  (ACETONURIA) 

Since  acidosis  involves  the  problems  of  metabolism  and  is  considered 
a  toxemia,  a  brief  reference  to  the  subject  is  included  for  convenience 
under  Intestinal  Auto-intoxication.  The  healthy  performance  of  the 
functions  of  the  tissues  depends  on  certain  chemical  processes  taking 
place  in  solutions  of  a  certain  composition,  the  chemical  reaction  of 
which  is  faintly  alkaline.  Any  disturbance  in  metabolism  which  tends 
to  reverse  the  condition,  that  is,  to  diminish  the  alkalinity  of  the  juices, 
may  set  up  a  condition  oj  acidosis.  This  disturbance  does  not  necessarily 
lead  to  an  actual  reduction  of  the  alkalinity  of  these  fluids;  the  blood,  for 
example,  since  considerable  quantities  of  acid  may  be  produced  in  the 
body  by  abnormal  metabolic  processes,  and  yet  lead  to  no  appreciable 
alteration  in  the  reaction  of  the  tissues  or  the  blood,  being  neutralized  by 
the  alkalis  in  the  body  fluids  and  cells  and  by  ammonia  produced  from 
the  hydrolysis  of  proteins,  which  would,  in  the  absence  of  the  call  for  an 
alkali,  have  been  converted  into  urea  and  excreted  in  that  form.  If  the 
amount  of  acid  ingested  or  produced  in  the  body  is  so  great  that  it  cannot 
be  neutralized  or  disposed  of  by  oxidation,  then  the  reaction  of  the  blood 
can  no  longer  remain  unaltered,  there  will  be  a  reduction  of  its  alkalinity, 
and  there  is  danger  of  the  condition  passing  from  the  milder  one  of  acidosis 
to  one  of  acid  intoxication. 

Acidosis  is  characterized  by  excretion  in  the  urine  of  an  excess  of 
acid  radicles,  acetone  alone  in  the  milder  cases,  and  diacetic  acid  in 
addition  in  the  more  severe  types,  and  these  two,  with  5-oxybutyric 
acid  as  well,  or  5-oxybutyric,  as  the  chief  in  the  most  severe  cases.  There 
is  sometimes  the  characteristic  sweet  odor  on  the  breath  from  the  acetone, 
particularly  in  diabetes  or  with  acid  intoxication. 

The  simplest  test  for  determination  of  acidosis  is  the  discovery  of 
one  or  more  in  these  acid  radicles — acetone  alone  or  the  others  in  addi- 
tion— in  the  urine.  The  amount  of  ammonia  in  the  urine  is  also  a  valuable 
^  Hexamethylenamin,  grs.  v-x  t.i.d.,  may  be  substituted. 


ACIDOSIS    (aCETONURIA)  58 1 

indication  of  the  degree  of  acid  poisoning,  and  the  odor  of  acetone  on  the 
breath.  The  determination  of  the  C02  tension  of  the  blood  plasma  by- 
Van  Slyke's  method,  will  afiford  information  in  suspected  cases  before 
acetone  appears. 

The  reduction  of  the  alkalinity  in  the  blood  further  shows  there  is 
danger  of  acidosis  passing  into  acid  intoxication.  In  severe  cases  of 
acidosis  the  reaction  of  the  urine  to  an  alkali  serves  as  a  test  as  to  the 
comparative  severity  of  the  process.  A  large  amount  of  bicarbonate 
of  soda  may  be  taken  without  producing  neutrality  or  alkalinity  of  the 
urine  in  severe  cases.  Fridderucia^  determines  the  degree  of  acidosis  in 
diabetics  by  means  of  measurement  of  the  carbon  dioxid  pressure  in  the 
expired  air;  with  an  increased  ammonia  excretion  there  is  an  abnormally 
low  carbon  dioxid  pressure. 

As  acidosis  may  exist  for  a  long  time  without  any  symptoms,  in  some 
cases  for  a  considerable  period,  and  in  others  with  none,  except  that 
the  patient  may  be  subject  to  digestive  disturbances,  and  since  this  mild 
type  of  acidosis  may  at  any  time  become  severe  and  even  result  in  danger- 
ous acid  intoxication,  the  urine  should  always  be  examined  for  acetone  as  a 
matter  of  routine.  This  is  particularly  true  in  early  pregnancy  and  in 
all  patients  about  to  be  operated  upon.  The  presence  of  even  a  small 
amount  of  acetone  previous  to  operation  would  contraindicate  chloroform, 
and  also  indicate  preparation  of  the  patient  by  the  administration  of 
soda  bicarbonate  previous  to  operation.  Other  anesthetics  such  as  ether 
and  nitrous  oxid  may  produce  acetonuria  as  well  as  chloroform.  In  fact, 
the  writer  believes  the  administration  of  an  alkali  (soda  bicarbonate) 
several  days  before  operation  is  an  excellent  procedure. 

James  Ewing^  divides  cases  of  acidosis  into  two  main  groups:  one 
without  fatty  degeneration  of  the  liver,  as  represented  by  diabetic  acidosis, 
and  one  with  fatty  degeneration,  represented  by  the  toxemia  of  preg- 
nancy, delayed  chloroform-poisoning,  Eck's  fistula,  cyclic  vomiting  in 
children,  and  poisoning  by  hematoxic  immune  serum. 

Acetone  bodies  are  found  in  the  urine  in  a  large  number  of  other 
clinical  conditions,  in  gastro-intestinal  diseases,  diseases  of  the  liver 
gastro-intestinal  diseases  accompanied  by  inanition,  starvation,  in 
some  cases  acute  yellow  atrophy,  phosphorus-poisoning,  chronic  renal 
disease.  Sellards^  has  made  an  important  clinical  study  of  acidosis  and 
of  its  occurrence  in  chronic  renal  disease.  Acidosis  of  high  degree  occurs 
in  renal  disease  particularly  in  the  uremia  of  acute  and  chronic  diffuse 
nephritis  and  it  often  appears  many  months  before  the  development  of 
uremia.  The  acidosis  is  probably  the  result  of  a  defective  function  of 
the  kidney  and  would  be  an  indirect  expression  of  renal  retention. 
Some  of  the  clinical  symptoms  of  uremia  are  partially  relieved  by  the 
injection  of  bicarbonate  of  soda.  Park^  reports  cases  of  ileocolitis  with 
acidosis  and  marked  respiratory  disturbances,  and  Singer^  a  case  of  severe 
auto-intoxication  with  acetonuria,  extreme  bradycardia,  and  convulsions. 

1  Zeitschrift  fiir  KUnische  Medizin,  vol.  Ixxx,  Xos.  i  and  2. 

*  Acidosis  and  Associated  Conditions,  Arch.  Int.  Med.,  1908,  ii,  330. 
^  Johns  Hopkins  Hosp.  Bull.,  May,  1914. 

*  Jour.  Amer.  Med.  Assoc,  Sept.  17,  1910. 
'  N.  Y.  Med.  Jour.,  June  26,  1909. 


582  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Deprivation  of  the  carbohydrates  and  dependence  on  protein  and 
fats  results  in  the  development  of  acetone  bodies  from  the  latter. 

The  ingestion  of  carbohydrates  is  followed  by  lessened  acetonuria, 
and  advantage  has  even  been  taken  of  this  in  the  acidosis  of  diabetes 
by  giving  temporarily  an  oatmeal  diet  to  relieve  the  acetonuria  and 
lessen  the  chance  of  a  subsequent  diabetic  coma.  Disturbance  of  the 
liver  functions,  with  interference  with  metabolism  as  a  result,  have, 
therefore,  an  influence  in  many  cases  as  noted  by  Ewing.  In  view  of 
the  occurrence  of  acetonuria  with  intestinal  auto-intoxication  and  ileo- 
colitis, etc.,  and  the  probable  damage  to  the  liver  cells  by  the  toxins, 
further  interference  with  metabolism  with  acetonuria  resulting,  would 
readily  suggest  itself.  Postoperative  vomiting  from  acidosis  may  be  a 
decided  menace  to  the  patient.  The  writer  has  recently  treated  two 
severe  cases  of  Virgil  P.  Gibney,  following  the  administration  of  ether. 
It  occurs  most  frequently  after  chloroform,  but  also  after  ethyl  chlorid 
and  nitrous  oxid. 

These  cases  were  both  girls,  aged  eight  and  nine  years,  with  a  previous 
history  of  weak  stomachs  and  possibly  cyclic  vomiting.  In  one  the 
vomiting  was  so  persistent  that  nutritive  enemata  and  saline  injections 
combined  with  180  grains  of  soda  bicarbonate  were  given  daily  for  a 
week.  There  was  acute  congestion  of  the  kidneys,  with  large  hemor- 
rhages of  visible  blood  on  two  occasions.  Albumin  and  casts  were  present, 
but  the  specific  gravity  was  low,  due  to  the  large  injections  of  saline  solu- 
tion by  rectum,  and  quite  marked  diuresis  resulted.  The  writer  reported 
in  the  Summer  Symposium  on  Acidosis  in  191 6,  American  Medicine,  a 
child  of  eight  years,  suffering  from  acidosis,  intestinal  putrefaction  and 
angioneurotic  edema  of  the  larynx  and  ascending  colon.  The  latter 
simulated  appendicitis.  In  all  cases  before  operation,  a  careful  examination 
of  the  urine  to  determine  whether  acetone  bodies  are  present  should  be 
made.  Preparatory  treatment  of  cases  with  acetone  in  the  urine  by 
administration  of  soda  bicarbonate  is  indicated,  and  the  administration  of 
oatmeal  with  glucose  or  lactose  for  several  days  is  of  value.  Sufficient 
sodium  bicarbonate  or  sodium  citrate  should  be  given  to  render  the  urine 
neutral  or  alkaline  for  several  days  before  operation  if  possible. 

It  has  been  the  author's  object  to  merely  briefly  call  attention  to 
this  interesting  problem  of  acidosis,  and  to  suggest  in  future  a  careful 
examination  of  the  urine  for  the  acetone  bodies  in  all  cases. 

BOTULISM 

This  is  a  variety  of  meat-poisoning  due  to  the  Bacillus  botulinus, 
isolated  by  Van  Ermengen  from  raw  ham.  The  symptoms  resembled 
those  of  so-called  sausage-poisoning.  This  same  type  of  poisoning 
has  occurred  from  eating  beans  that  were  imperfectly  canned.  These 
were  probably  infected  through  the  manure  of  pigs.  Meat  may  be 
extensively  infected  with  the  Bacillus  botulinus,  and  contain  a  large 
quantity  of  the  toxins,  without  showing  the  signs  of  decomposition. 
The  filtered  toxins  may  produce  the  effects. 

Incubation. — The  symptoms  seldom  appear  before  twelve  to  twenty- 
four  hours  after  ingestion  of  the  infected  meat.     They  are:  First,  dis- 


ENTEROGENIC   CYANOSIS  583 

turbances  of  the  external  muscles  of  the  eyeball,  such  as  ptosis,  abducens 
paralysis,  disturbances  of  associated  movements  with  nystagmus;  second, 
disturbances  of  the  internal  muscles  of  the  eyes,  such  as  enlargement 
and  rigidity  of  the  pupils;  third,  there  are  swelling  or  paralysis  of  the 
tongue,  pharyngeal  and  laryngeal  paralyses,  and  disturbances  of  the 
heart  and  respiration;  fourth,  there  may  be  weakness  or  paralysis  of 
motion.  Changes  in  sensibility  and  consciousness  usually  do  not  ac- 
company these  disturbances.  Fever  has  frequently  been  absent  and 
there  has  even  been  absence  of  disturbances  of  the  stomach  and  intestines. 
This  condition  is  not  so  rare  abroad  and  occurs  in  this  country. 

Treatment. — Evacuation  of  the  gastro-intestinal  tract.  Treatment 
of  symptoms.     Herter  recommends  Kempner's  antitoxin  when  procurable. 

HYDROGEN  SULPHID  AUTO -INTOXICATION 

In  health  the  formation  of  hydrogen  sulphid  seems  probably  limited 
to  the  large  intestine  and  a  small  adjacent  portion  of  the  small  intestine. 
Under  pathologic  conditions,  it  is  formed  in  other  parts  of  the  digestive 
tract.  In  chronic  ectasia,  hydrogen  sulphid  is  at  times  liberated  when 
putrefactive  changes  take  place.  Herter  believes  the  eructation  generally 
occurs  from  this  viscus,  so  that  no  symptoms  result.  He  holds  that  the 
stagnating  stomach  contents  probably  go  on  to  the  formation  of  cystin, 
and  that  the  Bacillus  lactis  aerogenes,  Bacillus  coli,  and  other  bacteria 
produce  hydrogen  sulphid  therefrom.  Senator^  reports  a  case  of  auto- 
intoxication from  hydrogen  sulphid  (hydro thionemia).  After  an  error  in 
diet,  the  patient  became  ill  with  gastro-enteric  catarrh.  On  the  third 
day  vomiting  accompanied  with  the  odor  of  hydrogen  sulphid  occurred. 
The  patient  became  dizzy  and  went  into  collapse,  without  loss  of  con- 
sciousness. The  eructation  of  gas  continued,  and  the  first  urine  gave 
the  reaction  of  hydrogen  sulphid.     The  case  recovered. 

Betz^  and  Stefanio  and  Emminghaus^  describe  cases.  Headache, 
dizziness,  delirium,  mental  depression,  drowsiness,  stupor,  and  collapse 
were  prominent  symptoms. 

Treatment. — Catarrh  of  the  gastro-intestinal  tract,  ectasia,  and  in- 
testinal putrefaction  must  receive  appropriate  treatment  as  required. 

ENTEROGENIC  CYANOSIS 

This  peculiar  type  of  auto-intoxication  was  first  described  by  Stokvis.^ 
The  patient,  aged  fifty-eight,  suffered  from  severe  enteritis  with  pro- 
nounced cyanosis  of  the  skin  and  visible  mucous  membranes,  together 
with  a  swelling  of  the  terminal  phalanges.  Spectroscopic  examination 
of  the  skin  and  mucous  membranes  showed  a  band  corresponding  to  the 
absorption  spectrum  of  methemoglobin.  It  was  believed  that  poison 
substances  were  formed  in  the  intestines  which  transformed  part  of  the 
hemoglobin  into  methemoglobin.     Talma^  reported  three  cases.     Van  der 

^  Berlin.  klin.Wochenschr.,  v,  p.  254,  1868. 

*  Memorabilien,  Ix,  p.  145,  1864. 

'  Berlin,  klin.  Wochenschr.,  ix,  pp.  447,  491,  1872. 

*  Festsch.  f.  V.  Leyden,  1,  p.  597,  1902. 

*  Tijdschrift  voor  Geneesk.,  li,  p.  721,  1902. 


584  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Bergh^  reported  two  cases,  one  of  which  was  evidently  due  to  sulphemo- 
globin  (from  hydrogen  sulphid)  in  the  blood,  and  in  the  other  the  blood 
contained  nitrites. 

Van  der  Bergh  also  reports  a  case  in  a  child  nine  years  of  age,  who 
suffered  from  marked  digestive  disturbances  with  diarrhea.  Anuria 
was  marked.  Child  was  very  cyanotic  and  the  ends  of  the  fingers  were 
clubbed;  abdominal  distention  marked.  Urine  contained  no  albumin, 
no  sugar,  but  a  little  indol.     No  cardiac  affection  present. 

Several  cases  of  sulphemoglobinemia^  have  been  associated  with 
obstinate  constipation,  the  relief  of  which  has  been  followed  by  improve- 
ment. 

Tecknic  of  Clinical  Spectroscopic  Blood  Examination. — Several  cubic 
centimeters  of  blood  are  obtained,  preferably  from  a  vein.  Examination 
can  be  made  by  drawing  a  few  drops  from  the  ear  or  finger.  The  blood 
should  be  drawn  directly  into  about  twice  its  volume  of  distilled  water. 
This  lakes  the  blood  and  gives  a  watery  solution  of  the  blood  pigment. 
The  solution  is  then  filtered  several  times  through  a  single  filter-paper  to 
remove  the  corpuscles  and  fibrin.  A  few  drops  of  this  solution  are  placed 
in  a  test-tube  or,  preferably,  in  a  glass  dish  or  bottle  with  parallel  sides, 
and  examined  with  the  spectroscope  by  transmitted  light.  To  the  speci- 
men distilled  water  is  added  drop  by  drop  until  the  dilution  is  obtained 
which  allows  a  good  transmission  of  the  red  light  only.  If  a  black  band  is 
seen  in  the  red,  the  blood  contains  either  methemoglobin  or  sulphemoglobin. 
If  the  band  persists  on  the  addition  of  a  few  drops  of  ammonium  sulphid, 
the  pigment  is  sulphemoglobin;  if  it  vanishes,  it  is  methemoglobin.  The 
addition  of  a  reducing  agent,  as  hydrazene  or  phenylhydrazene,  may 
intensify  a  sulphemoglobin  band  which  was  too  faint  to  be  seen  otherwise. 

Methemoglobin  results  from  drug  poisoning,  such  as  from  large 
quantities  of  bismuth  subnitrate,  or  from  auto-intoxication  from  ab- 
sorption of  nitrites  from  the  intestines  in  chronic  diarrhea;  while  sul- 
phemoglobin results  from  auto-intoxication  associated  with  chronic 
constipation,  the  result  of  hyperformation  or  hyperabsorption  of  H2S, 
or  of  the  presence  of  an  abnormal  reducing  agent  in  the  blood,  acting  with 
a  small  trace  of  H2S. 

Treatment. — This  should  be  directed  to  the  intestinal  tract.  Proteins 
should  be  reduced;  sour  milks  given;  purgatives;  enteroclysis  and  the 
general  treatment  of  intestinal  putrefaction  by  intestinal  antiseptics  are 
indicated. 

METEORISM  (TYMPANITES) 

This  is  defined  as  an  accumulation  of  gas  in  the  intestines.  Flatu- 
lence is  used  to  indicate  a  great  formation  of  gases  that  are  removed  by 
eructations  and  flatus. 

Part  of  the  gas  thus  accumulated  is  expelled  and  part  is  absorbed, 
and  thus  the  volume  of  gas  in  the  intestines  is  regulated. 

Etiology. — The  causes  of  tympanites  are  as  follows: 

I.  An  increased  introduction  (ingestion)  of  gas. 

^  Deutsch.  Archiv  f.  klin.  Med.,  xciii,  p.  86,  1905;  also  Berlin,  klin.  Wochenschr., 
No.  I,  p.  7,  1906. 

'  Clarke,  N.  Y.  Med.  Record,  Dec.  3,  1910. 


METEORISM    (tYMPANITES)  585 

2.  The  development  of  excessive  gas  within  the  intestines. 

3.  A  diminution  or  impairment  of  the  eliminative  power  of  the  in- 
testines for  gases. 

1 .  The  increased  introduction  of  gases  may  be  due  to  the  excessive  drinking 
of  aerated  beverages  or  the  swallowing  of  air. 

Aerophagy  (air  swallowing)  usually  occurs  in  hysteric  women,  and 
may  result  from  shock  or  emotional  disturbance.  It  is  generally  in- 
voluntary, due  to  spasm  of  the  pharynx.  The  symptoms  are  distention 
after  food,  loss  of  appetite,  frequent  noisy  eructations,  often  insomnia  or 
sleeplessness,  constipation.  Frequently  mucous  colic  or  gastroptosis 
(enteroptosis)  coexist.  Rapid  deglutition  movements  precede  the 
eructations. 

The  mucous  colic  or  enteroptosis  should  be  treated;  the  hysteria  com- 
bated; pharyngeal  spasm  checked  by  keeping  the  mouth  widely  open, 
applying  cocain  (i  per  cent.)  locally,  blisters  externally,  belladonna, 
bromids,  or  valerian  internally;  hypnotic  suggestion  in  some  cases; 
strychnin  to  stimulate  the  muscular  tone  of  stomach;  food  should  be 
concentrated. 

2.  Formation  of  Abnormal  Quantity  of  Gas  in  the  Intestines. — This 
may  be  due  to  fermentation  of  the  carbohydrates  or  to  putrefaction  of 
the  proteins.  An  excessive  amount  of  fermentable  or  putrefactive 
material  or  food  which  cannot  be  assimilated,  are  factors.  Catarrhal 
conditions  influence  the  activity  of  the  ferment  and  putrefactive  organisms. 

3.  Diminished  Elimination  of  Gases  from  the  Intestines. — This  is  due 
to  mechanical  obstruction  or  to  a  reduction  or  inhibition  (paralysis)  of  the 
muscular  power  of  the  intestinal  wall. 

Among  the  causes  are  stenosis,  intestinal  obstruction,  paresis  of  the 
intestines  in  the  infectious  diseases,  such  as  typhoid  fever,  pneumonia, 
cerebrospinal  meningitis,  peritonitis,  etc. 

In  pathologic  conditions,  where  there  is  circulatory  disturbance  in 
the  intestinal  walls,  as  in  peritonitis,  etc.,  absorption  of  gases  must  be 
interfered  with.     It  is  difficult  to  estimate  to  what  degree  this  is  a  factor. 

Nervous  Meteorism. — This  is  most  common  in  the  hysteric,  and  usually 
occurs  as  a  diffuse  distention  of  the  abdomen  (tympanites  hystericus), 
but  also  as  a  circumscribed  swelling  (phantom  tumor). 

Various  factors  have  been  suggested,  such  as  swallowed  air;  in- 
sufficiency of  the  pylorus,  allowing  passage  of  air  from  the  stomach  to 
the  bowels;  or  continuous  contraction  of  the  diaphragm  (Talma). 

With  narcosis,  the  abdomen  becomes  flaccid,  while  with  returning 
consciousness  meteorism  recurs,  and  air  cannot  be  detected  entering  or 
leaving  the  tract,  hence  Talma  denies  that  there  is  any  increase  of  gas  in 
the  intestines.  Some  attribute,  the  condition  to  acute  general  paresis, 
of  sudden  onset,  passing  off  rapidly,  analogous  to  other  hysteric  paralyses. 

Symptoms. — The  shape  of  the  abdomen  is  usually  altered,  a  feeling 
of  tension  is  almost  always  experienced.  With  general  meteorism  the 
abdomen  is  distended  quite  symmetrically,  while  with  partial  distention 
the  affected  parts  stand  out  in  marked  relief. 

With  local  distention,  the  coexistence  of  visible  peristalsis,  as  with 
stenosis,   sinplifies  the  diagnosis.     The  degree  of    distention    generally 


586  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

corresponds  to  the  amount  of  gas  present ;  but  the  weaker  the  muscles  and 
the  more  reduced  their  tone,  the  greater  is  distention.  An  example  of 
this  is  marked  tympanites  in  peritonitis. 

When  the  abdominal  muscles  are  tense,  sometimes  the  diaphragm, 
heart,  and  lungs  are  forced  upward,  and  severe  dyspnea  results,  which 
occasionally  may  be  followed  by  a  fatal  issue. 

In  severe  cases,  there  is  a  constant  feeling  of  pressure  and  a  desire  to 
pass  wind,  while  colicky  pains  are  sometimes  present.  As  a  rule,  no 
flatus  is  passed,  or  in  inconsiderable  amounts  at  long  intervals. 

Palpation  shows  the  abdominal  walls  are  very  tense.  They  present 
an  air-cushion  resistance.  The  percussion  note  is  abnormally  low  and 
loud,  the  tympanitic  ring  is  usually  lost.  With  auscultatory  percussion 
a  metallic  sound  is  elicited.  The  liver  dulness  may  be  reduced  and 
finally  disappear.  There  are  some  cases  of  meteorism,  in  which  the  wind 
is  passed  almost  constantly  from  the  anus  with  considerable  noise.  Rosen- 
heim believes,  as  these  gases  are  odorless,  that  the  air  is  pumped  into  the 
rectum  and  emitted  again  as  flatus. 

Prognosis. — If  occlusion  of  the  intestines  is  present,  the  outlook  is 
serious.     Ordinary  cases  are  favorable. 

Treatment. — This  should  be  directed  toward  removal  of  the  cause 
responsible  for  meteorism,  such  as  peritonitis,  typhoid,  stenosis,  etc. 

Drinks  and  foods  known  to  produce  flatulence  must  be  prohibited. 
Avoid  carbonated  waters,  beer,  champagne,  cider,  excessive  carbohydrates, 
rich  pastry,  etc. 

Intestinal  fermentation  or  intestinal  putrefaction,  if  they  cause  the 
meteorism,  must  be  treated  after  the  methods  already  described. 

Among  the  intestinal  antiseptics  are  ichthalbin,  ichthoform,  formidin, 
salol,  salicylate  of  soda,  benzonaphtol,  urotropin,^  and  sodium  benzoate, 
average  dose  of  each,  5  grains  (0.3)  t.i.d.  after  meals.  They  may  be 
given  in  shellacked  capsules.  Bismuth  salicylate  and  bismuth  subni- 
trate,  5  to  10  grains  (0.3-0.6)  t.i.d.,  are  of  service. 

Calcined  magnesia,  lime-water,  and  charcoal  are  suggested  to  absorb 
the  gas. 

In  mild  forms  of  flatulency  various  carminatives  have  been  employed, 
such  as  caraway  seed,  peppermint,  mint,  thyme,  cinnamon,  cloves,  anise 
seed,  nutmeg,  sassafras,  and  fennel.  These  are  best  given  as  infusions. 
Asafetida  and  the  oil  of  cloves  are  believed  by  Brunton  to  aid  absorption 
of  CO2  and  H2S. 

Cathartics  and  laxatives  may  be  necessary  when  there  is  no  peritonitis 
or  obstruction.  Physostigmin  salicylate,  3^00  to  }4o  grain  (0.0006-0.001), 
has  been  recommended  in  severe  cases. 

Massage,  abdominal  douches,  electricity,  and  electric  enteroclysis  are 
of  service  in  cases  where  there  are  no  anatomic  lesions.  Friction  of  the 
abdomen  with  spiritous,  aromatic,  or  ethereal  substances,  such  as  cam- 
phorated oil,  turpentine,  oil  of  cajeput,  etc.,  are  serviceable. 

The  introduction  of  a  colon-tube  may  aid  the  escape  of  gas.  Water 
enemata  of  soapsuds,  containing  spirits  of  menth.  piperit.,  i  dram  (4.0), 
or  oil  of  turpentine,  i  dram  (4.0),  are  useful. 

'  Hexamethylenamin,  grs.  v-x  t.i.d.,  may  be  substituted. 


INTESTINAL    PAIN    (INTESTINAL    COLIC;    ENTERALGIA)  587 

Puncturing  the  intestines  with  a  trocar  is  a  dangerous  procedure. 

Meteorism  in  the  hysteric  occasionally  disappears  without  treatment. 
Attention  should  be  paid  to  the  nervous  condition.  Valerian  and  asafetida 
are  useful  by  mouth  or  enema  in  such  cases. 

Pill  asafet.,  one  t.i.d.;  emulsion  (milk)  asafet.,  i  to  2  ounces  (30.0- 
60.0),  by  enema. 

Zinc  valer.,  2  grains  (0.125),  or  ammon.  valer.,  5  grains  (0.3),  t.i.d. 

Tinct.  valer.  and  tinct.  lavend.  co.,  aa  2  ounces  (60.0).  Dose,  i 
dram  (4.0)  of  the  mixture  in  water  t.i.d.  after  food.  Iron,  arsenic,  and 
strychnin  are  of  tonic  value  in  the  nervous  cases. 

Massage,  friction,  and  a  tight  abdominal  band  are  useful. 

INTESTINAL  PAIN  (INTESTINAL  COLIC;  ENTERALGIA) 

Intestinal  pain  can  be  distinguished  as  follows: 

1.  Pain  originating  from  inflammation  of  the  intestinal  wall  or  of  its 
peritoneal  coat. 

2.  Pain  of  colic. 

3.  Nervous  enteralgia,  described  under  Neuroses. 

Colic  is  the  painful  stimulation  of  the  intestinal  nerves  which  is 
produced  by  severe  tonic  contractions  of  the  intestines.  G.  F.  Shiels^ 
holds  that  the  pain  is  produced  in  the  peritoneal  coat.  Kast  and  Meltzer 
have  demonstrated  by  a  series  of  experiments  that  the  intestines  are 
sensitive  to  pain. 

Etiology. — Organic  lesions  of  the  intestines,  excess  in  or  improper 
articles  of  food,  cold  drinks,  substances  causing  marked  gas  formations, 
fecal  accumulation,  intestinal  worms,  foreign  bodies,  gall-stones,  entero- 
liths, tainted  foods,  large  quantities  of  mucus,  as  in  mucous  colic,  exposure 
to  cold,  gout,  occasionally  ulcers,  internal  strangulation  of  the  bowels, 
stenosis,  purgatives,  lead-  and  copper-poisoning  may  produce  colic. 

Symptoms. — The  pain  of  colic  is  peculiar — pinching,  boring,  or 
occasionally  of  a  tearing  character — it  occurs  in  paroxysms  which  may 
last  a  few  seconds  or  be  prolonged  several  hours.  It  usually  appears 
suddenly  and  disappears  as  rapidly.  Its  intensity  may  be  so  severe 
that  fainting  and  collapse  occur. 

If  colic  begins  from  error  in  diet,  there  may  be  gastric  disturbances, 
belching,  nausea,  and  vomiting.  Obstinate  constipation  and  flatulence 
may  be  present,  or  if  the  cause  be  from  improper  food,  diarrhea.  The  pain 
frequently  starts  at  the  umbilicus  and  remains  localized  or  radiates  in 
other  directions.  The  face  of  the  patient  shows  his  suffering.  Pressure 
over  the  abdomen  relieves  the  pain  in  some,  while  in  others  it  increases  it. 
There  may  be  straining  sensations  in  the  bladder  and  rectum  and  occa- 
sionally borborygmi  can  be  heard.  Persistaltic  movements  can  be  seen 
in  thin  patients.  If  accumulated  fecal  masses  and  gas  are  evacuated 
spontaneously  or  by  injections,  the  attack  rapidly  subsides. 

Spastic  contractions  of  the  intestines  may  be  encountered.  If  they 
involve  a  large  part  of  the  bowels,  as  in  lead-colic,  the  abdomen  appears 
trough  shaped.     In  stercoral  and  wind-colic,  it  is  usually  tympanitic. 

1  Amer.  Jour,  of  Surgery,  April,  1908. 


588  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

Diagnosis. — In  enteralgia  due  to  anatomic  lesions  of  the  intestines, 
the  pain  is  increased  by  pressure.  There  is  frequently  diarrhea  and  the 
stools  contain  blood,  mucus,  and,  rarely,  pus. 

With  rheumatism  of  the  abdominal  muscles,  the  pain  is  superficial 
and  not  within  the  abdominal  cavity.  It  often  changes  its  location. 
Pressure  increases  the  pain,  while  rest  and  antirheumatic  medicines 
diminish  it.  With  lead  colic  we  have  the  history,  blue  line  on  the  gums, 
peripheral  neuritis,  steppage  gait,  paralysis  of  various  muscles,  wrist  drop, 
saturnine  arthralgias  and  in  the  blood,  excessive  granular  basophilic 
degeneration. 

With  peritonitis  there  are  fever,  tenderness  on  pressure,  muscular 
rigidity,  meteorism,  absence  of  abdominal  respiration,  increase  of  poly- 
nuclears,  and  leukocytosis. 

Hyperesthesia  of  the  abdominal  wall  usually  occurs  in  hysteria  and 
neurasthenia.  The  pains  are  superficial,  lying  chiefly  in  the  skin.  The 
faradic  current  often  removes  the  pain.  Biliary  and  renal  colic  are 
recognized  by  the  location  of  the  pain  and  characteristic  symptoms. 
Neuralgic  pains  are  superficial  and  radiate. 

F*rognosis. — These  cases  end  in  recovery,  with  rare  exceptions. 

Treatment. — For  the  relief  of  pain,  morphin  by  hypodermic  K  to  >^ 
grain  (0.008-0.016),  or  codein,  the  same  or  even  a  double  dose,  or  tincture 
of  opium,  10  minims  (0.59  c.c),  heat  to  the  abdomen,  and  hot  saline  enema 
or  enteroclysis  at  ii5-i2o°F.     Squibb's  mixture  is  useful. 

Later,  the  bowels  should  be  throughly  evacuated  by  an  enema,  the 
simple  soapsuds,  enema,  i  quart  (liter),  or  which  may  contain  ^  pint  (250 
c.c.)  of  olive  oil  and  i  dram  (4.0),  of  spirits  of  turpentine.  A  cathartic, 
castor  oil,  i3'2  ounces  (45.0),  or  calomel,  5  grains  (0.3),  followed  by  a 
saline  cathartic,  should  be  given. 

The  cause  of  the  colic  should  be  corrected,  as  should  any  errors  in 
diet.     Fluid  diet  should  be  employed. 

Tincture  of  belladonna,  5  to  10  minims  (0.3-0.6),  the  writer  finds 
of  value  for  the  spasm. 

For  lead  colic,  as  prophylactic,  among  all  lead  workers,  the  hands  should 
be  thoroughly  cleansed  before  eating,  no  food  should  be  taken  on  the 
factory  premises.  Sulphuric  acid  lemonade  has  been  suggested.  Potas- 
sium iodid  gr.  v-x  t.i.d.  is  of  value  and  magnesium  sulphate  when  costive. 
Hot  baths  and  electricty  to  the  paralyzed  muscles  are  serviceable. 

VISCERAL  ARTERIOSCLEROSIS 

Harlow  Brooks^  calls  to  our  attention  that  the  presence  of  diminished 
visceral  function,  with  occasional  and  otherwise  unaccountable  elevations 
of  the  blood-pressure,  should,  particularly  in  connection  with  possible 
etiologic  factors,  lead  to  a  suspicion  of  some  localized,  if  not  general,  area  of 
arterial  disease.  When  associated  with  pain  of  peculiar  anginal  character, 
location  in  some  special  organ  may  be  within  the  range  of  possibility.  I 
feel  quite  certain  that  careful  observation  of  cases  of  obscure  abdominal 
pain,  paroxysmal  in  character  and  associated  with  elevation  of  the  blood- 

'  Amer.  Jour.  Med.  Sci. 


VISCERAL   ARTERIOSCLEROSIS  589 

pressure,  will  eventually  make  it  possible  to  diagnose  these  generally 
unrecognized  types  of  arterial  disease  while  in  a  stage  when  something  may 
still  be  done  for  their  alleviation  or  for  the  prevention  of  their  further 
progress. 

Etiology. — Alcohol,  nephritis,  syphilis,  old  age,  tuberculosis,  tobacco 
excesses,  and  toxemia  are  the  chief  causes.  Intestinal  toxemia  is  respon- 
sible for  a  considerable  number  in  my  opinion. 

Some  of  these  patients  give  a  history  of  nervousness,  gastric  catarrh, 
and  pain;  vomiting  and  even  hematemesis  may  occur.  Meteorism  and 
constipation  are  not  uncommon.  The  epigastrium  may  be  distended  and 
tender.  Anginoid  attacks  may  occur  with  rapid,  slow  or  irregular  pulse, 
with  salivation  and  sweating.  Pain  over  the  pancreas  and  intestinal 
functional  disturbances  have  been  noted.  When  such  symptoms  occur 
in  a  patient  with  well-marked  arteriosclerosis,  and  are  relieved  by  iodids 
and  nitrates,  one  is  justified  in  diagnosing  abdominal  arteriosclerosis. 
The  determination  of  increased  blood-pressure  by  means  of  the  sphygmo- 
manometer aids  the  diagnosis  of  the  milder  types  of  such  cases.  This 
method  should  always  be  employed.  Under  Indicanuria  the  writer  re- 
ports an  interesting  case. 

Perutz^  shows  we  must  differentiate  between  angina  pectoris  and 
angina  abdominis  due  to  arteriosclerosis: 

I  have  recently  seen  several  cases  who  have  complained  of  pain  in 
the  epigastrium,  belching,  constipation,  and  headache.  The  gastric 
analysis  showed  deficient  hydrochloric  acid  secretion  and  the  pulse  the 
characteristics  of  arteriosclerosis.  Treatment  afforded  no  relief  until  the 
nitrites  were  administered.  "Gilbride^  reports  a  number  of  cases  with 
symptoms  of  pain  in  the  epigastric  or  umbilical  regions,  rarely  in  the  lower 
abdomen.  This  is  increased  by  exertion  and  in  some  cases  during  diges- 
tion. Weakness,  loss  of  weight,  abdominal  distention,  and  belching  are 
present.  Bowels  are  constipated,  or  there  is  constipation  alternating  with 
diarrhea,  or  occasionally  normal  movements.  There  may  be  vertigo  or 
disturbances  of  vision.  The  gastric  analysis  showed  in  most  cases  defi- 
ciency of  hydrochloric  acid;  in  one  it  was  nearly  absent  and  in  one  normal. 
Stomach  motility  normal  or  increased.  Lactic  acid  and  Boas-Oppler 
bacilli  were  absent.  Cancer  has  been  suspected.  The  radial  pulse  and 
blood-pressure  may  show  arteriosclerosis.  In  some  cases  there  are  no 
evidences  of  this,  but  there  are  two  symptoms  significant  of  abdominal 
arteriosclerosis — tenderness  of  the  abdominal  aorta  with  epigastric  pulsation. 
Some  patients  may  have  attacks  of  angina  pectoris  with  pain  referred  to 
the  epigastrium.  The  age  of  the  patient  is  usually  over  forty."  Ortner^ 
has  contributed  to  the  subject,  demonstrating  the  disturbances  of  the 
motor,  secretory,  and  absorptive  functions  of  the  intestines  due  to  arterio- 
sclerosis; and  Akin"*  has  reported  several  cases.  Nitrites  afford  the  most 
relief,  with  the  addition  of  potassium  or  sodium  iodid.     Tincture  aconite 

^  Miinch.  Med.  VVochenschr.,  May  28  and  June  4,  1907. 

2  Gastro-intestinal  Disturbances  Due  to  Arteriosclerosis,  Jour.  Amer.  Med.  Assoc, 
March  20,  iqoq. 

'  Volkmann,  Samml.  klin.  Vortr.,  No.  347. 
••  Jour.  Amer.  Med.  Assoc,  June  5,  1909. 


590  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

(35  P^r  cent,  old  pharmacopoea)   5   to   10  drops  t.i.d.,  aid  in  lowering 
excessive  high  tension. 

SENILE  DYSPEPSIA 

The  dyspepsia  of  old  age  has  been  investigated  by  Fen  wick/  who 
shows  that  in  every  100  cases  of  chronic  dyspepsia  in  persons  over  sixty- 
five  years  of  age,  66  are  secondary  to  organic  diseases  of  some  important 
organs  of  the  body,  while  34  owe  their  symptoms  to  a  progressive  de- 
generation of  the  secretory  structures  of  the  stomach  and  intestines. 
Disease  of  the  kidneys,  heart,  lungs,  liver,  or  a  gouty  condition  all  have  a 
bearing  in  a  large  percentage  of  cases  on  the  gastro-intestinal  disturbances 
of  the  aged,  and  in  a  certain  number,  gastric  hypersecretion  of  long  dura- 
tion from  an  old  gastric  or  duodenal  ulcer  may  be  a  factor.  Chronic 
appendicits  or  fibroid  degeneration  of  the  appendix  may  also  result  in 
gastro-intestinal  disturbances. 

In  about  one-third  of  the  cases,  no  organic  change  can  be  located 
in  any  particular  organ.  There  is,  however,  an  impairment  of  the 
secretory  functions  of  the  digestive  tract,  the  general  assimilative  powers 
decline,  the  body  assimilates  less  organic  matter,  and  destroys  less  in- 
organic material  with  a  resulting  waste  of  tissue  in  many  cases.  In 
others  disturbances  of  metabolism  occur,  which  result  in  obesity  and  in 
the  derangement  of  the  eliminative  functions.  In  such  there  is  associated 
frequently  fatty  degeneration  of  the  organs. 

Even  though  there  be  no  marked  evidences  of  general  arteriosclerosis, 
the  author  believes  these  disturbances  of  the  gastro-intestinal  functions 
in  the  aged  to  be  in  most  cases  a  manifestation  of  visceral  arterioslcerosis, 
varying  from  a  mild  to  a  severe  type,  with  resulting  damage  to  the  glands 
presiding  over  the  functions  of  digestion. 

Undoubtedly,  the  condition  of  the  mouth,  deficiency  or  absence  of 
teeth,  decayed  roots,  with  associated  putrefaction  in  the  mouth,  all 
have  an  influence.  Insufficient  mastication  also  has  a  bearing  on  the 
subject. 

Gastric  Analysis. — Examination  of  the  gastric  contents  after  the 
test-breakfast  shows  a  diminution  of  free  hydrochloric  acid  (hypo- 
chlorhydria) ,  and  sometimes  even  achylia  gastrica. 

Intestinal  Functions. — The  functions  of  the  intestinal  digestion 
should  be  tested.  Intestinal  fermentation  or  intestinal  putrefaction 
are  present. 

Symptoms. — Belching  of  gas  and  flatulence  occur.  Constipation 
is  usually  present,  though  in  some  it  alternates  with  a  diarrhea.  Many 
cases  suffer  from  loss  of  appetite  and  from  insufficient  nutrition  and 
there  is  loss  of  weight  as  a  result. 

Other  patients  are  of  a  different  type  and  are  obese.  They  suffer 
from  belching  of  gas  and  flatulence.  Their  appetite  is  good,  in  fact, 
cannot  be  satisfied,  but  elimination  is  imperfect.  The  stomach  is  atonic, 
but  pyloric  insufficiency  is  often  present.  There  is  atonic  constipation, 
but  it  frequently  alternates  with  lienteric  diarrhea. 

^  London  Lancet,  Nov.  6,  1909. 


SENILE    DYSPEPSIA 


591 


The  first  class  of  patients,  the  asthenic  type,  Niles'  classifies  as  hyper- 
koric  dyspepsia,  in  whom  there  is  early  satiety  for  food,  loss  of  appetite, 
or  even  sitophobia.  As  a  result  scarcely  sufiicient  food  is  ingested  to 
properly  support  life. 

The  second  class,  the  obese  or  sthenic  type,  he  characterizes  as  akoric 
dyspepsia,  since  they  are  never  satiated. 

One  also  meets  among  the  aged  cases  with  very  marked  symptoms 
such  as  described  under  Visceral  Arteriosclerosis. 

Diagnosis. — The  diagnosis  can  be  made  by  exclusion  of  other  fac- 
tors, taken  in  association  with  the  age  of  the  patient.  The  determination 
of  increased  blood-pressure  by  means  of  the  sphygmomanometer  is  also 
of  value.     It  should  always  be  employed. 

Treatment. — The  mouth  should  be  cleansed  with  boric  acid,  glyco- 
thymolin,  listerin,  borolyptol,  or  some  mild  antiseptic  several  times  daily. 
Old  roots  and  decayed  teeth  should  be  extracted  and  artificial  teeth  should 
be  worn,  so  that  the  patient  can  masticate  properly.  Active  catharsis 
should  be  avoided;  simple  remedies,  such  as  purgen,  cascara,  phenolax, 
regulin,  and  small  enemataof  olive  oil, ^  are  indicated.  Dilute  hydrochloric 
acid  with  nux  vomica  should  be  given  for  the  subacidity.  A  convenient 
preparation  is  oxyntin  with  nux  vomica  in  capsules,  5  to  10  grains  (0.3- 
0.5)  t.i.d.,  before  or  after  meals.  Taka-diastase,  5  grains  (0.3)  t.i.d.,  is 
valuable  to  aid  starch  digestion,  and  holadin,  5  to  10  grains  (0.3-0.5) 
t.i.d.,  or  some  other  pancreatic  preparation  for  intestinal  dyspepsia. 

Other  remedies  are  noted  under  the  section  on  that  subject.  The 
nitrites,  nitroglycerin,  Hoo  to  3^0  grain  t.i.d.,  or  more  frequently, 
should  be  administered  for  the  arterial  condition  or  tinct.  aconite  (35  per 
cent.),  5  to  8  drops  t.i.d.,  and  the  iodids  may  be  added,  sodium  iodid,  5 
grains  (0.3)  t.i.d.,  preferably,  as  it  causes  less  disturbance  of  the  stomach. 

Exercise. — Those  cases  characterized  by  malnutrition  should  take  a 
minimum  amount,  but  be  in  the  fresh  air  as  much  as  possible,  while 
activity  is  indicated  for  the  obese  within  the  limits  of  fatigue. 

Diet. — Food  should  be  prepared  in  the  most  digestible  form.  It  is 
preferable  to  administer  four  or  five  small  meals  daily  to  three  large  ones. 
In  the  asthenic  cases  with  malnutrition,  food  of  a  high  calorie  value,  such 
as  fats  and  starches  carefully  prepared,  are  indicated,  while  patients  of 
obese  type  should  receive  a  minimum  of  these.  In  these  cases,  the 
frequent  small  meals  relieve  best  the  sensation  of  hunger.  The  above 
rules  are  only  general. 

As  the  condition  is  one  of  deficient  hydrochloric  acid  secretion,  the 
diet  can  be  much  the  same  as  for  achylia  gastrica. 

In  the  earlier  stage  of  treatment,  peptonized  milk  may  be  given  for  a 
brief  period.  Matzoon,  koumiss,  lactone-buttermilk,  bacillac,  fermillac, 
eggs,  and  barley  and  rice  gruel.  Excessive  fluids,  however,  tend  to 
produce  too  much  gas  in  some  patients. 

Small  quantities  of  thicker  gruels  and  soups,  such  as  pea,  strained  bean, 
potato,  barley,  rice,  and  sago  often  agree.  Fenwick  holds  that  barley, 
oatmeal,  and  rice  must  be  given  with  caution.     Much  depends,  however, 

'  Amer.  Jour.  Med.  Sci.,  Jan.,  191 1. 

2  Olive  oil  by  mouth,  or  Russian,  or  American  mineral  oil  are  of  service. 


592  DISEASES    OF   THE    STOMACH   AND  INTESTINES 

on  the  cooking  of  the  cereal,  which  must  be  thorough,  and  it  should  be 
passed  through  a  colander  so  to  ensure  removal  of  the  membranous 
coverings. 

As  the  patient  improves,  meat  should  be  given  in  small  quantities  and 
finely  minced,  such  as  fish,  chicken,  game,  calves'  brains,  sweet-bread, 
calves'  feet,  rare  or  raw  scraped  beef,  and  pigeon. 

Fats,  such  as  butter  or  cream,  must  be  tried  on  the  sthenic  cases  suffering 
from  malnutrition.  They  sometimes  agree  and  at  times  not.  The  diet 
must  be  necessarily  modified  by  the  conditions  found  in  the  functions  of 
the  intestine,  which  as  noted  should  be  determined.  Red  meat  should 
be  avoided  when  there  is  intestinal  putrefaction  of  a  marked  character  or 
when  high  blood  pressure  and  the  condition  should  receive  treatment. 
Toast  baked  in  the  oven  to  dry  it  out  and  zwieback  are  preferable  to  bread. 
Crackers  are  admissible,  green  vegetables  and  oranges  may  be  tried.  If 
plain  milk  disagree  and  peptonized  milk  be  disagreeable,  a  little  lime-water 
or  citrate  of  soda  may  be  added  to  the  milk. 

Tropon,  or  somatose  may  be  added  to  the  milk  or  gruels. 

ANOMALIES  IN  THE  POSITION  AND  FORM  OF  THE  INTESTINES; 

ENTEROPTOSIS 

Various  anomalies  in  the  position  and  form  of  the  intestines  occur,  in 
some  cases  congenital  and  in  others  acquired,  of  which  Koch  and  Curshman 
have  made  a  study. 

They  may  be  congenital  in  some  cases,  acquired  through  coprostasis, 
the  weight  of  a  tumor,  or  the  formation  of  adhesions,  in  the  majority  of 
cases  the  colon  being  affected.  Various  angulations  of  the  sigmoid,  espe- 
cially due  to  adhesions,  are  described  by  the  late  J.  P.  Tuttle.  Inflation 
with  air  and  the  use  of  bismuth  injections  with  the  rc-ray  aid  diagnosis. 

Dilatation  of  the  Colon. — There  are  three  varieties  of  dilated  colon 
usually  described :  First,  the  Makro-colic,  an  elongation  of  the  colon  with  no 
deviation  from  its  normal  circumference;  second,  megalocolic  (large 
colon)  with  uniform  increase  in  its  internal  diameter  and  a  relative  thick- 
ening of  its  walls;  third,  ecta-colic  (dilated  colon),  a  congenital  form,  an 
extensive  dilatation  of  the  colon  with  or  without  hypertrophy  and  dilata- 
tion of  the  adjacent  section  of  the  intestine.  The  prognosis  of  the  first 
type  is  fairly  good  under  medical  treatment,  while  in  the  last  two,  it  is 
not  so. 

Hirschsprung's  disease,  or  congenital  primary  dilatation  and  hyper- 
trophy of  the  colon,  is  found  at  birth.  Dyspeptic  symptoms,  obstinate 
constipation,  and  colicky  pains  with  great  distention  are  present.  By 
insertion  of  a  finger  or  catheter  into  the  rectum  a  movement  will  occur  with 
relief  of  the  distention.  A  large  percentage  of  cases  of  Hirschsprung's 
disease  die  in  early  childhood.  This  is  one  condition  in  which  the  writer 
believes  that  if  there  is  no  improvement  under  medical  treatment  by 
enteroclysis,  electricity,  etc.,  after  a  short  period  of  time,  better  results 
are  secured  by  removing  the  dilated  colon,  or  by  laparotomy  with  separa- 
tion of  adhesions  if  such  cause  the  dilatation. 

Idiopathic  dilatation  of  the  colon  is  a  rare  event,  and  enteroptosis, 
the  most  common  displacement,  is  described  under  Gastroptosis. 


INTESTINAL    SAND  593 

Idiopathic  dilatation  of  the  colon,  in  which  there  is  no  mechanical 
obstruction  to  the  feces,  may  be  congenital,. develop  early  or  later  after 
birth,  or  be  acquired  in  adult  life.  Nervous  derangement,  habitual  con- 
stipation, rickets,  or  chronic  colitis  may  be  factors.  The  colon  and  espe- 
cially the  sigmoid  are  greatly  distended,  so  that  the  protrusion  of  the  ab- 
domen may  justify  the  term  "balloon  man."  Ulceration  may  occur  in 
the  distended  gut.  Constipation  or  irregularity  of  the  bowels,  gaseous 
distention,  intestinal  putrefaction,  shortness  of  breath,  palpitation,  edema 
of  the  legs  from  pressure  on  the  vena  cava  occur. 

Treatment. — Enteroclysis,  ox-gall  enemata  or  simple  enemata  which 
should  be  small  so  not  to  overdistend,  resorcin,  gr.  v  t.i.d.  and  salol,  gr.  v 
t.i.d.  to  diminish  gas,  strychnin,  gr.  %0-yio  t.i.d.  to  improve  bowel  tone, 
or  occasionally  physostigmine  salicylate,  gr.  3d!oo  once  or  twice  daily, 
electricity  and  massage  if  there  are  no  ulcers,  regulation  of  the  bowels, 
and  treatment  of  indicanuria  are  indicated.  The  diet  should  be  laxative. 
Iron  and  cod-liver  oil  are  of  value.  Abdominal  support  is  of  service. 
Operative  procedure  may  be  required,  such  as  colon  resection,  with 
junction  of  the  ileum  to  the  sigmoid. 

INTESTINAL  SAND 

This  material  is  gritty,  contains  organic  matter,  inorganic  salts,  espe- 
cially calcium  phosphate  and  carbonate,  but  no  cholesterin,  which  distin- 
guishes it  from  biliary  sand. 

It  has  been  considered  by  others  as  a  manifestation  of  the  arthritic 
diathesis.  It  is  usually  associated  with  mucous  colic  or  possibly  constipa- 
tion.    It  occurs  generally  in  women  between  thirty  and  forty  years  of  age. 

The  associated  condition  must  be  treated.  Sodium  bicarbonate  5ss 
t.i.d.  and  bismuth  salicylate  gr.  x  t.i.d.  have  been  recommended. 

False  intestinal  sand,  such  as  the  residue  of  vegetable  food,  especially 
from  pears,  must  not  be  mistaken  for  true  sand.     Symptoms  are  abswit. 


38 


CHAPTER  XXII 
INFECTIONS  BY  THE  BAQILLUS  COLI 

Invasion  of  the  kidneys  by  the  colon  bacillus  is  not  a  particularly 
uncommon  occurrence.  As  the  author^  has  diagnosed  this  condition  as 
a  serious  complication  in  a  number  of  cases  of  typhoid  fever,  and  as  he 
has  furthermore  observed  the  invasion  of  other  organs  by  the  colon  bacil- 
lus, it  seems  proper,  in  view  of  its  source,  that  this  infection  should  be 
described  in  this  volume.  The  colon  bacillus  has,  furthermore,  a  definite 
relation  to  certain  infections  in  the  gastro-intestinal  tract.  For  example, 
it  has  been  found  as  a  factor  in  acute  appendicitis  and  also  in  the  fluids  of 
acute  peritonitis.  It  has  been  responsible  for  inflammation  of  the  pan- 
creas, for  gall-bladder  inflammation,  and  colon  bacilli  have  been  found 
as  the  nucleus  of  gall-stones  and  pancreatic  calculi. 

Furthermore,  Fen  ton  B.  Tiirck  has  fed  colon  bacilli  to  dogs  and  has 
experimentally  produced  gastric  ulcer  in  these  animals.  Injections  of  the 
B.  coli  have  also  produced  gastric  ulcer. 

Reference  has  been  made  to  Herter's  investigations  into  intestinal 
putrefaction  as  to  the  influence  of  the  Bacillus  aerogenes  capsulatus  in 
the  production  of  pernicious  anemia.  The  possibility  that  this  last  condi- 
tion may  at  times  be  the  result  of  colon  bacilli  infection  is  suggested  by 
A.  Charlton^  in  his  researches  at  McGill  University,  in  an  article  entitled 
"On  the  Anemia  Produced  by  Repeated  Injections  of  Cultures  of  a 
Colon  Bacillus  of  Low  Virulence."  Striking  results  followed  intravenous 
injections — the  experiments  being  carried  on  for  many  weeks. 

They  were  as  follows:  Advanced  anemia  occurred,  in  some  respects 
strikingly  like  the  conditions  found  in  pernicious  anemia,  namely,  a  great 
diminution  in  the  number  of  red  cells,  marked  poikilocytosis,  the  appear- 
ance of  pear-shaped  cells,  crescents,  macrocytes,  microcytes,  and,  lastly, 
nucleated  red  cells.  On  suspension  of  the  injections  for  some  weeks,  even 
when  the  fall  of  erythrocytes  was  from  550,000  to  only  1,500,000,  spon- 
taneous recovery  took  place. 

When  injection  of  the  bacilli  was  resumed,  the  injurious  results  were 
more  marked  than  before.  But  in  addition  to  the  effects  on  the  blood, 
strikingly  progressive  changes  were  produced  in  the  spinal  cord,  consisting^ 
of  diffuse  degeneration  in  the  columns  of  GoU,  and  in  the  anterolateral 
columns  of  the  cord,  closely  resembling  the  conditions  occurring  in  the 
spinal  cord  in  some  cases  of  pernicious  anemia;  extreme  emaciation  oc- 
curred— the  animals  dying  apparently  from  pure  asthenia,  though  they 
fed  well  and  suffered  from  no  gastro-intestinal  disturbances.  Wm.  H. 
Thomson^  compares  this  condition  to  progressive  anemia  with  emaciation 
and  nervous  weakness,  grouped  under  the  vague  term  neurasthenia. 

*  Boston  Med.  and  Surg.  Jour.,  Nov.  30,  191 1. 

*  Jour,  of  Med.  Research,  vol.  viii,  No.  2,  Nov.,  1902. 

*  Med.  Rec,  May  28,  1910. 

';94 


INFECTIONS  BY   THE  BACILLUS    COLI  595 

H.  G.  Harris^  of  New  York  has  reported  an  interesting  case  of  infantile 
paralysis  in  which  colon  bacilli  were  found  in  large  numbers  in  the  urine. 
The  patient  recovered  under  the  use  of  urotropin.  In  view  of  the  changes 
produced  in  the  spinal  cord  experimentally  by  the  injection  of  colon  bacilli 
into  the  circulation,  the  clinical  case  cited  is  of  interest. 

Method  of  Infection  by  the  Colon  Bacillus. — Some  suggest  that  the 
origin  of  colon  bacilluria  is  due  generally  to  the  introduction  of  these  organ- 
isms from  without  (ascending  infection).  Thus,  catheterization  is  given  as 
a  cause.  Box  holds  that  he  has  found  this  condition  more  frequently 
among  girls  than  boys,  and  explains  it  by  the  short  urethra  in  the  former, 
which  more  readily  allows  entrance  of  the  bacilli.  He  states  there  is  no 
more  common  cause  of  enuresis  among  children  than  the  presence  of  this 
bacillus.  While  doubtless  these  organisms  may  enter  the  bladder  through 
the  urethra  instead  of  descending  from  the  infected  kidneys,  it  is  difficult 
to  account  for  the  persistent  enormous  multiplication  of  these  bacilli  in 
the  urine,  when,  unlike  all  urines  decomposed  by  other  bacteria,  in  colon 
bacillus  cases  it  remains  strongly  acid  and  not  alkaline,  and  gives  ofif  no 
ammoniacal  odor.  Of  course,  in  all  cases  of  organs  infected  other  than 
those  of  the  urinary  tract,  the  bacilli  must  come  through  the  blood,  and 
it  is  the  author's  belief  that  in  most  cases  the  bacilluria  results  from  auto- 
infection  from  the  intestinal  tract — in  some  cases  the  bacilli  causing  an 
active  process  in  the  kidneys — while  in  others  a  few  bacilli  are  eliminated 
through  these  organs  without  clinical  symptoms  for  a  considerable  period. 
As  a  rule,  there  is  some  ulcerative^  process  in  the  intestinal  canal,  or  in 
some  cases  probably  a  mere  solution  of  continuity.  Chronic  constipation 
alone  may  suffice  to  allow  the  occurrence  of  chronic  infection  from  the 
colon.     The  possibility  of  entrance  through  the  tonsils  has  been  suggested. 

In  fact,  two  such  cases  have  been  reported.  Infection  by  contiguity 
may  also  occur,  as  by  rupture  of  an  abscess,  and  infection  through  the 
lymphatic  system  may  also  be  possible.  Hematogenous  infection — i.e., 
through  the  blood — is  the  most  common  method. 

Types  of  Infection  Produced  by  the  Colon  Bacillus. — Among  the  types 
of  infection  produced  by  the  colon  bacillus  are  acute,  subacute,  and  chronic 
nephritis,  pyelitis,  pyelonephritis,  pyonephrosis  (50  out  of  60  cases  of 
Lenhartz  due  to  colon  bacillus),  septic  infarcts  of  the  kidney,  cystitis, 
enuresis,  septic  endocarditis,  otitis,  meningitis,  infantile  paralysis,  pros- 
tatitis, seminal  vesiculitis  and  urethritis.  Berstein^  also  reports  a  case  of 
brain  abscess  due  to  the  bacillus  coli.  Daugherty^  reports  a  number  of 
cases  of  infection  of  the  middle  ear,  one  of  which  was  complicated  by  brain 
abscess,  all  of  which  were  produced  by  colon  bacillus  infection.  Cases  of 
aggravated  constipation  which  exhibit  typhoidal  symptoms  are  occasion- 
ally met  with,  in  which  isolation  from  the  urine  and  blood  of  the  Bacillus 
coli  communis,  or  positive  and  exclusive  agglutination  of  the  patient's 
serum  against  most  strains  of  this  organism,  prove  these  cases  to  be  a  gen- 
eral infection  with  the  colon  bacillus.     An  epidemic  of  this  type  has  been 

^  N.  Y.  Med.  Jour.,  April  i,  191 1. 

*  W.  H.  Thomson,  Acute,  Subacute,  and  Chronic  Infection  of  the  Kidneys  and  of 
Other  Organs  by  the  Bacillus  Coli,  Med.  Rec,  May  28,  1910. 

*  Med.  Rec,  Feb.  7,  1914. 

*  N.  Y.  Med.  Jour.,  Dec.  12,  1914. 


596  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

reported  in  Bavaria.^  Phlegmonous  enteritis  (colon  infection)  is  recorded. 
Apparent  rheumatic  articular  attacks  have  been  reported  due  to  colon 
bacillus  infection  and  have  been  cured  by  autogenous  vaccines.  The 
writer  knows  of  one  case  apparently  secondary  to  cholecystitis,  where  the 
colon  bacilli  were  found  on  blood  culture  and  the  case  cured  by  vaccines. 

Attacks  of  intermittent  fever,  the  fever  coinciding  with  the  appearance 
of  colon  bacilli  in  the  urine,  and  the  intermission,  with  their  disappearance 
have  been  reported.  Recently  I  have  treated  such  a  case.  Intra-abdom- 
inal exudates  and  tumors,  believed  to  be  tubercular  or  cancerous,  have  been 
demonstrated  to  be  pure  colon  bacilli  infections.  Cases  simulating  per- 
nicious anemia  may  be  due  to  this  infection,  and  choroiditis  has  also  been 
reported  as  due  to  the  same  cause.  Gastric  ulcer  and  achlorhydria  hsemor- 
rhagica  gastrica  secondary  to  a  primary  appendicitis  infected  by  the  colon 
bacillus  are  also  possibilities.  The  author  reports  in  this  article  a  case  of  a 
private  patient  at  the  New  York  Hospital,  who  was  under  his  care,  who 
suffered  from  general  infection  with  the  colon  bacillus.  This  patient  had 
a  double  pyelitis,  cystitis,  double  pneumonia,  purulent  bronchitis,  two 
attacks  of  acute  colitis,  and  myocarditis,  all  in  succession,  and  ultimately 
recovered.  Colon  bacilli  were  present  in  the  urine  and  sputum  in  enor- 
mous numbers.  In  acute  pancreatic  disease  and  acute  cholecystitis  this 
type  of  infection  must  be  considered,  and  in  cases  of  acute  postoperative 
general  hemorrhagic  attacks  in  patients  with  gall-stones  and  pancreatitis. 
The  writer  has  treated  a  case  of  chronic  pancreatitis  due  to  colon  bacilli 
infection. 

Subdiaphragmatic  abscess  and  wound  infection  by  colon  bacilli  may 
also  occur.  Three  cases  of  onynychia  due  to  colon  bacillus  are  reported. 
Reference  has  previously  been  made  to  the  fact  that  colon  bacilli  are  found 
as  a  nucleus  of  gall-stones  and  pancreatic  calculi,  and  to  Harris'  case  of 
apparent  infantile  paralysis  with  colon  bacilli  in  the  urine,  cured  by  the 
administration  of  hexamethylenamin.  Experiments  have  also  demon- 
strated the  possibility  that  colon  bacilli  may  be  factors  in  the  production 
of  cirrhosis  of  the  liver. 

Reaction  of  the  Urine  in  Colon  Bacillus  Infection. — The  urine  reaction 
is  acid  in  colon  bacillus  infection.  Some  claim  it  is  at  times  alkaline,  but 
the  writer  has  not  found  this  so,  unless  after  the  administration  of  large 
quantities  of  water  or  of  alkalis. 

Symptoms  of  Colon  Bacillus  Infections. — On  account  of  the  diversity 
of  these  infections,  it  seems  best  to  the  author  to  illustrate  them  by  various 
cases.  Acute  infection  of  the  kidneys  will  be  first  described.  An  inter- 
esting case  is  reported  by  Wm.  H.  Thomson^  in  consultation  with  Robert 
Abbe: 

"On  the  fifth  day  after  operation  for  pelvic  tumor,  the  patient  com- 
plained of  cramps  and  pain  in  the  abdomen  extending  to  the  rectum. 
These  were  accompanied  by  nausea  and  frequent  vomiting,  followed  by  a 
rise  of  temperature  to  io4.3°F.  The  patient  then  became  drowsy  and 
apathetic,  with  muscular  twitchings  in  the  face  and  upper  extremities. 
The  wound  was  healthy  and  healed  by  first  intention.     These  symptoms 

*  De  Haan  and  De  Gouge:  Laboratte  Weldobrecken  Mederlingen,  Bavaria,  1902. 

*  Med.  Rec,  May  28,  1910. 


INFECTIONS   BY   THE  BACILLUS    COLI  597 

cleared  up.  On  the  twenty-second  day  after  the  operation  the  patient  had 
slight  chills  lasting  twenty  minutes,  rise  of  temperature  to  103. 5°F.,  with 
the  development  of  the  symptoms  described  above.  In  addition  the  pulse 
became  rapid,  small,  and  irregular.  The  chills,  sudden  onset,  early  cere- 
bral symptoms,  which  may  pass  into  coma  or  delirium,  but  no  convulsions, 
rapid  rise  of  temperature,  and  some  vomiting,  Thomson  believes  pathog- 
nomonic of  involvement  of  the  kidneys  by  some  septic  organism,  of  which 
the  colon  bacillus  is  the  most  common.  The  following  day  the  urine  be- 
came loaded  with  pus,  blood,  and  casts,  and  colon  bacilli  were  found  in 
large  numbers  in  the  urine. 

"On  account  of  the  vomiting,  hexamethylenamin  and  sodium  benzoate, 
each  10  grains,  were  administered  by  rectum  every  three  hours.  As  the 
patient  also  had  oliguria  (16  to  26  ounces  daily),  enteroclysis  with  Kemp's 
tube  was  ordered  A.  M.  and  P.  M.,  2  gallons  of  normal  saline  solution  at 
1 1 5°F. ;  the  urine  increased  up  to  from  60  to  1 1 2  ounces  in  twenty-four  hours. 
During  the  course  of  a  week  the  pus  and  blood  cleared  up.  The  urine 
continued  acid  with  a  specific  gravity  averaging  1008,  but  it  still  showed 
a  diffused  white  cloud.  This  is  characteristic  and  is  caused  by  immense 
numbers  of  colon  bacilli  in  suspension.  The  cerebral  symptoms  and 
vomiting  ceased  within  twenty-four  hours  after  initial  treatment,  and  the 
temperature  fell  to  99°F.,  and  thence  to  normal.  The  bacilluria  still 
persisted  until  on  the  twentieth  day  she  developed  symptoms  of  subacute 
appendicitis.  Abbe  operated  under  local  anesthesia,  and  removed  a  dis- 
eased appendix  with  several  hemorrhagic  points  in  its  lumen  and  a  large 
ulcer  in  its  base  at  the  junction  with  the  cecum.  The  bacilli  subsequently 
disappeared  from  the  urine.  Though  the  treatment  alleviated  the  severe 
symptoms,  the  focus  of  infection  was  present  until  removed."  Chas.  R. 
Box,  of  St.  Thomas  Hospital,  London,  in  an  article  in  the  Lancet^  observes 
that  in  many  cases  where  the  kidneys  are  involved  in  typhoid  fever ,  scarlet 
fever,  measles,  and  diphtheria,  the  organism  found  in  the  urine  is  the  colon 
bacillus. 

In  view  of  this  fact,  the  colon  bacillus  should  be  examined  for  in  all 
cases.  In  any  event,  even  if  not  found,  it  would  seem  to  the  author  that 
the  large  doses  of  hexamethylenamin  and  sodium  benzonate  are  the  best 
disinfectants  for  the  kidneys. 

Wm.  H.  Thomson^  reports  an  interesting  case  of  A.  Seibert,  of  New 
York,  during  the  course  of  scarlatina.  Dr.  Seibert  found  the  girl,  age 
eleven,  in  the  sixth  week  of  her  illness,  suffering  from  universal  edema, 
most  marked  in  the  face,  some  ascites,  pulse  48,  intermitting  every  third 
beat.  She  was  semiconscious,  with  total  blindness,  which  had  persisted 
for  five  days,  nausea,  and  incessant  vomiting,  which  had  lasted  for  ten 
days,  necessitating  rectal  feeding.  Two  severe  uremic  convulsions  had 
occurred  on  the  previous  day.  Only  4  or  5  ounces  of  urine  had  been  passed 
in  the  previous  twenty-four  hours,  and  this  contained  but  a  moderate 
amount  of  albumin.  Hexamethylenamin,  5  grains  dissolved  in  i  ounce  of 
cold  water,  with  15  drops  of  dilute  hydrochloric  acid,  was  administered 
and  retained.    The  same  dose  of  hexamethylenamin  was  continued  every 

^*  Jan.  II,  1908. 
*Med.  Rec,  March  21,  1908;  May  28,  1910. 


598  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

three  hours.  The  headache  first  disappeared,  marked  diuresis  set  in,  so 
that  no  ounces  of  urine  were  passed  in  the  next  twenty-four  hours,  and 
all  the  edema  disappeared  within  forty-eight  hours.  The  amaurosis 
diminished  in  two  days  and,  finally,  disappeared  in  a  week,  after  which 
she  made  an  uninterrupted  recovery. 

A  second  illustrative  case  is  that  of  a  physician  who  had  been  treated 
for  chronic  ulcerative  colitis  and  who  had  had  a  rectal  ulcer  excised. 
Shortly  after  this  he  became  delirious,  with  moderate  temperature.  This 
condition  lasted  four  weeks.  The  urine  was  examined  daily  by  an  expert, 
who  reported  blood,  albumin,  and  many  casts — laboratory  diagnosis, 
acute  parenchymatous  nephritis.  Thomson,  on  being  called  in  consulta- 
tion, finding  that  the  patient  had  no  edema,  that  the  pulse  was  soft,  and 
the  delirium  prolonged  and  active,  which  were  not  common  in  parenchy- 
matous nephritis — also  being  cognizant  of  the  history  of  intestinal  ulcera- 
tion— diagnosed  infection  of  the  kidneys  with  the  colon  bacillus,  and  re- 
quested examination  of  urine  for  the  same.  Meanwhile  his  usual  treat- 
ment, hexamethylenamin  and  sodium  benzoate,  each  10  grains  every 
three  hours,  was  ordered.  It  was  first  given  by  rectum.  The  laboratory 
report  showed  colon  bacilli  in  abundance.  Two  days  later  the  blood, 
albumin,  and  casts  disappeared,  and  six  months  later  the  physician  re- 
ported sixteen  hours  professional  work  a  day. 

T3rphoid  Fever. — Acute  invasion  of  the  kidneys  by  the  bacillus  coli  is 
not  uncommon,  and  is  at  times  a  fatal  complication  of  typhoid  fever, 
especially  in  the  later  stages  of  extensive  ulceration.  Sudden  severe  rigors 
occurring  late  in  the  disease,  increased  albuminuria  and  casts,  often  with 
diminished  urine,  and  at  times  with  commencing  delirium,  are  all  signifi- 
cant of  colon  bacillus  infection.  The  urine  should  at  once  be  examined 
for  the  bacilli,  and  the  usual  treatment,  hexamethylenamin  40  to  80  grains 
daily,  and  sodium  benzoate,  an  equal  amount,  instituted.  The  author  has 
had  numerous  such  cases  during  the  past  few  years. 

Pyelitis. — Acute  invasion  of  the  kidneys  may  be  productive  of  a  simple 
pyelitis,  usually  bilateral,  attacking  first  one  and,  after  subsidence  of  the 
acute  symptoms,  then  the  other  organ. 

There  is  then  a  subsidence  of  symptoms,  but  recurrences  take  place 
usually  in  one  kidney,  and  these  continue  until  final  cure.  There  is  a 
sudden  rise  of  temperature,  103°  to  io5°F.,  often  preceded  by  a  chill; 
first  one,  and  later,  frequently  the  other  kidney,  becomes  tender  on  pres- 
sure. There  is  pain  in  the  lumbar  region,  urine  is  highly  acid,  contains 
pus,  occasionally  blood,  and  is  loaded  with  colon  bacilli.  The  pyelo- 
nephritis of  pregnancy,  particularly  postpartum,  is  quite  frequently  the 
result  of  colon  bacillus  infection.  L.  C.  Dudgeon,^  in  his  Erasmus  Wilson 
lecture  on  Acute  and  Chronic  Infections  of  the  Urinary  Tract,  also  de- 
scribes such  cases.  He  reports  that  such  attacks  sometimes  occur  with 
appendicitis.  Finding  such  cases  prone  to  relapse,  he  recommends  treat- 
ment with  vaccines.  As  a  matter  of  routine,  the  author  believes  that  in 
all  cases  of  pyelitis  one  should  examine  the  urine  for  colon  bacilli.  The 
dose  of  hexamethylenamin  usually  given  is  too  small,  as  will  be  described 
under  Treatment.  If  appendicitis  is  present,  as  in  some  of  Dudgeon's 
^  The  Lancet,  Feb.  29,  1908. 


INFECTIONS   BY    THE   BACILLUS    COLI  599 

cases,  it  should  be  removed,  as  it  is  the  source  of  infection  under  such 
conditions. 

Acute  Unilateral  Septic  Infarcts  of  the  Kidney. — George  E.  Brewer^ 
reports  several  cases  in  which  the  lesions  were  confined  to  one  kidney. 
This  condition  may  be  due  to  pure  cultures  of  the  staphylococcus  pyogenes 
aureus,  virulent  forms  of  streptococci,  and  in  one  case  the  organism  was  the 
Bacillus  coli.  Other  authors  mention  the  latter  as  a  frequent  cause  of 
this  condition.  The  symptoms,  which  are  sudden  in  their  onset,  are  chills, 
a  temperature  rising  rapidly  to  103°  to  io5°F.,  to  even  io6°F.,  tenderness 
over  the  kidney,  especially  at  the  costovertebral  angle  (Brewer's  point); 
pus,  albumin,  casts,  and,  at  times,  blood  are  present  in  the  urine,  and  colon 
bacilli  when  such  are  the  cause  of  the  infection. 

The  cause  of  unilateral  infarctions  can  be  readily  explained  by  the 
probable  occurrence  of  preceding  lesions  in  this  organ — according  to  the 
principle  illustrated  by  S.  J.  Meltzer — who,  on  producing  minute  lesions 
with  long  needles  in  the  liver,  kidneys,  and  other  organs  of  rabbits,  and 
then  injecting  a  virulent  culture  in  the  vein  of  the  ear,  produced  abscesses 
only  at  the  seat  of  these  traumatisms.  Infarctions  occasionally  occur  in 
both  kidneys,  so  that  differential  urethral  catheterization  will  absolutely 
determine  the  correctness  of  the  diagnosis  as  to  whether  one  or  both  are 
involved. 

Chronic  Interstitial  Nephritis. — Wm.  H.  Thomson  holds  that  this  con- 
dition may  be  primarily  caused  by  slow  infection  of  the  kidneys  by 
the  Bacillus  coli.  Sudden  terminations  of  cases  of  chronic  instertitial 
nephritis,  characterized  by  oliguria  or  suppression  of  urine,  are  nearly 
always  preceded  by  acute  indigestion  in  some  form,  and  Thomson  always 
dreads  an  attack  of  so-called  cholera  morbus  in  an  elderly  patient,  and 
at  once  examines  thfe  urine. 

These  cases  are  frequently  attributed  to  an  acute  exacerbation  of  the 
chronic  kidney  disease,  whereas  numbers  of  such  cases  have  been  saved 
by  immediate  resort  to  hexamethylenamin  and  sodium  benzoate,  admin- 
istered by  rectum  when  the  patients  were  comatose.  He  holds  that  it  is 
suggestive  how  soon  in  the  course  of  chronic  interstitial  nephritis  symptoms 
of  increased  kidney  affection  develop  after  errors  of  diet.  The  author, 
under  Indicanuria,  has  called  attention  to  the  acute  kidney  disturb- 
ance produced  by  intestinal  putrefaction,  and  also  noted  the  value  of 
hexamethyleifamin  and  sodium  benzoate  for  the  treatment  of  this 
condition. 

Cholecystitis. — Inflammation  of  the  gall-bladder  is  frequently  pro- 
duced by  the  colon  bacillus,  which  may  reach  it,  as  it  does  probably  most 
frequently  through  the  gall-duct,  or,  at  times,  through  the  blood-stream 
or  lymphatics. 

At  the  Johns  Hopkins  Hospital  the  gall-bladders  of  animals  were 
infected  with  the  colon  bacillus,  and  subsequently  cured,  or  inflammation 
prevented  by  the  administration  of  hexamethylenamin.  It  would  seem 
wise  to  examine  the  urine  for  colon  bacilli  in  all  cases,  and  in  any  event 
to  administer  hexamethylenamin  to  disinfect  the  gall-bladder,  in  all 
irkfections  of  that  viscus. 

^  Surgery,  Gynecology,  and  Obstetrics,  vol.  ii,  No.  5. 


600  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

H.  Batty  Shaw^  gives  the  histories  of  seven  cases  of  his  own  of  colon 
bacilli  infection,  in  which  he  states  that  clinically  such  patients  may  be 
supposed  to  be  sufferers  from  malaria,  tuberculosis,  mucous  colitis,  recur- 
rent cystitis,  dyspepsia,  acute  suppression  of  urine,  typhoid  fever,  or 
pernicious  anemia.  He  recommends  that  every  case  of  chronic  febrile 
affection  of  obscure  origin  should  have  the  urine  examined  for  the  Bacillus 
coli. 

The  author  has  recently  treated  a  case  of  chronic  pancreatitis  with 
marked  steatorrhea  and  colon  bacilluria.  In  view  of  an  old  history  of 
intestinal  ulcer,  the  possible  influence  of  colon  bacillus  infection  in  the 
production  of  chronic  pancreatitis  is  suggested. 

Choroiditis. — Robert  T.  Morris^  reports  the  case  of  a  patient  referred 
to  him  by  John  S.  Kirchendall,  of  Ithaca,  who  suffered  from  choroiditis, 
which  threatened  to  end  in  blindness.  Morris  found  that  for  years  the 
patient  had  suffered  from  intestinal  troubles  due  to  fibroid  degeneration 
of  the  appendix,  and  on  its  removal  the  patient  recovered,  both  from  the 
intestinal  dyspepsia  and  also  from  the  choroiditis.  Stockton,  of  Buffalo, 
has  for  years  asserted  that  the  colon  bacillus  was  the  cause  of  many  cases 
of  choroiditis.  The  author  has  seen  a  case  of  choroiditis  suffering  from 
gastro-intestinal  disturbances,  in  whom  marked  colon  bacilluria  was  found. 
This  was  treated  by  large  doses  of  hexamethylenamin,  grs.  60  daily,  given 
in  divided  doses  with  apparent  improvement  in  the  ocular  symptoms. 

Pelvic  Exudate  and  Intra-abdominal  Tumors  Due  to  Colon  Bacillus 
Infection. — F.  Charlton  Briscoe,^  Physician  to  Kings  College  Hospital, 
London,  relates  several  instances  of  the  matting  together  of  the  pelvic 
viscera  by  an  exudate,  showing  caseous  changes,  which  led  to  a  mistaken 
clinical  diagnosis  of  tubercular  nature,  but  which  proved,  on  microscopic 
examination,  to  be  caused  by  the  Bacillus  coli.  In  each  case  colon  bacilli 
were  found  abundantly  in  the  urine. 

Case  I. — This  patient  was  a  woman  with  rectal  ulcer  and  chronic 
hemorrhoids,  who  gradually  lost  weight,  with  daily  fever  and  constant 
pain  in  the  right  flank.  These  were  evidences  of  an  intra-abdominal  mass. 
On  laparotomy,  the  pelvic  organs  were  found  matted  together,  the  uterus, 
posterior  wall  of  the  bladder,  and  a  coil  of  the  small  intestine  being  bound 
together.     Under  treatment  by  vaccines,  she  fully  recovered. 

Case  2. — This  patieHt  suffered  from  intra-abdominal  tumor,  with 
temperature.  The  condition  was  thought  to  be  tubercular.  On  laparot- 
omy, a  large  mass  of  caseous  material  was  found  attached  to  the  small 
intestine,  great  omentum,  left  ovary,  and  tube.  This  was  thought  to  be 
surely  tuberculous,  but  no  tubercle  bacilli  were  found.  There  was  a 
structureless  material  from  which  pure  cultures  of  colon  bacilli  were 
obtained. 

Case  3. — In  an  Italian  woman,  age  fifty-two,  there  was  a  large  tumor 
which  was  suspected  to  be  malignant.  On  laparotomy,  it  was  found  to 
be  attached  to  the  wall  of  the  bladder  and  extended  from  the  pelvis  to 
the  umbilicus.     It  was  of  dark  red  color  and  covered  with  peritoneum. 

^Clinical  Jour.,  Feb.  12,  1908. 
'^N.  Y.  Med.  Jour.,  Jan.  i,  1910. 
3  The  Lancet,  Oct.  30,  1909. 


INFECTIONS   BY    THE   BACILLUS    COLI  6oi 

There  were  many  large  blood-vessels  passing  over  its  surface.  On  the 
supposition  that  it  was  malignant  and  inoperable,  it  was  let  alone.  For 
three  days  after  the  temperature  rose  daily  to  io3°F.,  and  on  the  fourth 
day  she  passed  a  considerable  quantity  of  pus  and  large  flakes  of  lymph  in 
the  urine.  The  tumor  was  found  to  have  disappeared,  but  from  time  to 
time  it  re-formed  and  emptied  itself,  eventually  disappearing  entirely. 
From  the  urine  a  pure  culture  of  Bacillus  coli  was  obtained. 

Briscoe  further  refers  to  an  interesting  number  of  cases  who  have 
attacks  of  intermittent  fever,  the  temperature  coinciding  with  the  ap- 
pearance of  colon  bacilli  in  the  urine,  and  the  intermissions,  with  their 
disappearance.  He  advises  that  the  urine  be  examined  for  colon  bacillus 
in  all  cases  of  fertile  attacks  of  obscure  origin.  He  also  notes  how  frequently 
ulcers  in  the  rectum  occur  previous  to  invasion  of  the  kidneys  and  other 
organs.  He,  together  with  other  authors,  comments  on  the  pale  color 
of  the  urine,  the  milky  haze,  acid  reaction  and  high  specific  gravity,  to- 
gether with  the  chronic  persistence  of  the  colon  bacilli,  when  they  once 
appear  in  the  urine.  He  also  notes  that  the  urine  never  decomposes  with 
an  ammoniacal  odor.     The  urine  is  always  acid. 

Briscoe  makes  the  urine  alkaline,  gives  frequent  mercurial  purges, 
and  administers  autogenous  vaccination,  the  initial  dose  being  50,000,000 
of  the  dead  organisms  every  seven  to  eight  days,  with  effective  results. 

Wound  Infection  with  the  Colon  Bacillus. — The  writer  has  seen  a 
number  of  cases  of  wound  infection  with  the  colon  bacillus,  notably  several 
cases  after  operation  for  appendicitis.  E.  A.  Babler^  reports  a  case  fol- 
lowing gunshot  wound  of  the  liver  and  colon,  and  an  interesting  case  of 
subphrenic  abscess  with  destruction  of  part  of  the  diaphragm  and  marked 
necrosis  of  the  tissues  and  skin.     The  condition  is  depicted  in  Fig.  282. 

Septic  onychia  due  to  the  colon  bacillus  has  been  reported  by  Houston.^ 
All  the  patients  were  cured  by  autogenous  vaccines. 

Finally,  the  author  reports  a  case  of  general  infection  with  colon  bacilli, 
in  which  the  organisms  were  found  both  in  the  urine  and  in  the  sputum. 
This  patient  ultimately  recovered.  The  case  was  of  such  severity  and 
suffered  from  so  many  complications  that  it  is  described  at  length. 

H.  G.,  broker,  aged  forty-four,  operated  on  at  the  New  York  hospital 
by  Frank  Hartley,  for  right  inguinal  hernia.  The  subsequent  complica- 
tions were  as  follows,  all  due  to  infection  with  the  colon  bacillus:  Double 
pyelitis,  cystitis,  double  pneumonia,  purulent  bronchitis,  two  attacks  of 
acute  colitis,  and  a  myocarditis. 

On  March  i,  1910,  the  patient  entered  the  New  York  hospital.  Pre- 
vious to  admission  heart,  lungs,  and  urine  were  found  to  be  normal. 
These  findings  were  confirmed  at  the  hospital  before  operation.  His 
weight  was  165  pounds,  height  5  feet  11}^  inches,  was  in  perfect  physical 
condition,  smokes  a  pipe  several  times  a  day,  and  for  two  years  has  not 
indulged  in  alcohol  except  an  occasional  Scotch-with-soda  when  dining 
out.  Urine  has  been  normal  for  two  years  before  operation.  Previous 
to  this  time  a  few  casts  and  a  trace  of  albumin  were  found  for  a  brief 
period  of  several  weeks.     Alcohol  was  shut  off  and  diet  instituted,  and  urine 

^  Jour,  Amer.  Med.  Assoc,  Oct.  29,  1910. 
^Lancet,  May  23,  1914. 


6o2 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


rapidly  returned  to  normal,  in  which  condition  it  remained.  The  patient, 
though  very  active  as  to  exercise,  has  always  had  a  tendency  to  constipa- 
tion. He. has  secured  bowel  action  by  olive  oil  internally  and  other  simple 
remedies. 

March  2d.     Operation  for  a  rather  small  reducible  hernia. 

Catherterization  was  required  the  afternoon  of  the  day  of  operation. 
On  the  following  day  there  was  some  irritation  of  the  bladder,  which  was 
washed  out  once,  and  on  the  day  after  this,  a  pain  in  left  kidney  first  began. 
Urine  showed  pus — diagnosis,  left  pyelitis — no  examination  for  colon 
bacilli  was  made  at  this  time.  Hexamethylenamin,  10  grains  t.i.d.,  was 
given,  and  an  ice-bag  was  applied  to  kidney.  The  tenderness  disappeared 
within  three  or  four  days,  and  then  an  attack  began  in  the  right  kidney, 
but  of  not  so  great  severity.  The  pain  in  the  right  kidney  rapidly  dis- 
appeared, but  pus  persisted  in  the  urine  and  also  a  slight  temperature. 


■~^f^".*^^ '  ^w 


Fig.  282. — Subphrenic  abscess  (colon  bacillus  infection)  (Babler). 

On  Friday,  March  nth,  the  patient  complained  of  pains  on  the  right  side 
of  the  chest,  and  on  March  12th  (Saturday)  Hartley  found  a  slight  dry 
pleurisy,  increasing  up  to  March  i3th.  On  March  14th  the  writer  was 
requested  to  examine  the  patient,  and  on  that  date  found  a  small  pneu- 
monic area  at  the  right  base.  The  operating  surgeon  thereupon  requested 
me  to  take  charge  of  the  case.  March  i6th  there  was  a  sudden  attack  of 
heart  failure,  accompanied  by  a  fall  in  temperature.  The  patient  was 
nearly  pulseless  in  spite  of  heroic  stimulation  and  oxygen.  Hartley  and 
S.  Lambert  (the  consultants)  believed  he  would  die  at  any  moment. 
Digitalone,  15  drops,  and  sodium  caffein  salicylate,  2  grains,  were  admin- 
istered every  four  hours;  also  strychnin  sulphate,  }4o  grain,  every  four  hours 
— one  given  at  2,  6,  10,  etc.,  the  other  at  4,  8,  12,  etc. — so  that  stimulants 
were  administered  every  two  hours.  In  addition,  the  writer  had  given 
hourly  a  hypodermic,  5  grains  of  camphor  in  olive  oil,  for  sixteen  hours, 
in  all,  80  grains  during  this  period. 


INFECTIONS  BY    THE  BACILLUS    COLI  603 

The  patient's  chest  was  kept  thoroughly  oiled  to  prevent  blistering, 
and  boiling  hot  stupes  were  applied  every  three  minutes  over  the  heart 
and  thorax  continuously  for  seven  and  one-half  hours;  then  an  intermission 
of  one-half  hour,  then  renewal  for  four  hours  continuously,  and  so  on. 
In  all,  during  the  twenty-four  hours,  hot  stupes  were  applied  for  twenty 
hours. 

As  there  was  some  distention,  the  head  of  the  bed  was  blocked  up  to 
prevent  pressure  (gas)  on  the  thorax,  and  the  stupes  were  carried  down 
over  the  abdomen.  The  writer  believes  the  application  of  continuous 
extreme  heat  and  the  camphor  injections  were  the  chief  factors  in  saving  the 
life  of  the  patient  in  the  acute  heart  failure  attack.  He  was  given  40  to 
50  grains  of  camphor  daily  for  some  days  by  hypodermic,  in  addition  to 
the  other  stimulants  noted.  For  several  days  no  food  was  administered, 
only  hot  water. 

On  March  19th  some  increase  in  temperature  occurred,  showing  further 
involvement  of  the  lung  at  the  right  base;  the  temperature  at  no  time  was 
very  high,  and  after  two  to  three  days  gradually  defervesced. 

At  midnight,  March  24th,  the  patient  was  suddenly  taken  with  an 
extremely  severe  chill,  lasting  about  half  an  hour;  the  respirations  rapidly 
increased,  and  when  the  writer  saw  him  at  i  A.  M.,  March  25th,  they 
averaged  65  to  70  per  minute,  the  heart  action  was  rapid,  and  the  patient 
was  suffering  for  lack  of  oxygen.  Continuous  hot  stupes,  oxygen,  camphor 
and  strychnin,  in  about  an  hour  gradually  relieved  the  condition,  the 
respirations  gradually  diminishing  in  frequency.  The  temperature  shot 
up  to  io4°F.,  then  dropped  to  normal,  and  then  gradually  rose  to  101° 
to  ioi.5°F.  Hartley  and  S.  Lambert  saw  the  case  at  once,  and  suspecting 
the  possibility  of  complicating  empyema,  Hartley  put  in  aspirating  needles 
in  several  locations,  with  negative  results. 

As  there  was  no  apparent  cause  for  this  condition,  and  as  the  pyelitis 
was  still  in  evidence,  hexamethylenamin  30  grains  a  day,  had  been  resumed 
after  the  acute  stage  of  pneumonia  had  passed.  The  writer  having  had 
a  number  of  cases  of  colon  bacillus  infection  with  the  same  type  of  chill 
and  temperature  noted  in  this  case,  requested  an  examination  of  the 
urine  for  this  organism,  and  on  suspicion,  increased  the  hexamethylenamin 
to  10  grains  every  three  hours,  adding  sodium  benzoate,  an  equal  amount, 
for  the  next  twelve  hours. 

In  the  morning  a  large  number  of  Gram-negative  bacilli  were  reported 
under  the  microscope.  The  hexamethylenamin,  10  grains,  and  sodium 
benzoate,  10  grains,  were  continued  every  three  hours,  both  day  and 
night,  a  total  of  80  grains  each  per  day,  and  later  pure  cultures  of  colon 
bacilli  were  reported  in  the  urine.  The  temperature  gradually  defervesced 
to  about  99.5°F.,  where  it  remained.  Resolution  of  the  right  lung  was 
very  slow,  there  was  little  expectoration,  but  abundant  colon  bacilli  were 
found  in  the  sputum.     The  following  events  then  occurred: 

In  early  May  a  sharp,  attack  of  acute  colitis,  no  blood  or  occult  blood 
could  be  found;  intestinal  irrigations  with  acetozone  (i  :  1000)  were  given; 
lactic  acid  bacilli  tablets  begun  and  kept  up  thereafter. 

Early  in  May  a  second  pneumonia  at  the  left  base  developed,  very 
slight  with  mild  symptoms;  temperature  slight  and  with  no  cardiac  dis- 


604  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

turbance;  it  was  slow  to  resolve;  undoubtedly  the  saturation  of  the  patient 
with  hexamethylenamin  was  contributory  to  its  mildness.  Colon  bacilli 
were  again  found  in  the  sputum. 

Blood-culture  Taken  at  this  Time  and  Found  Sterile. — In  the  middle  of 
May  a  sudden  attack  of  acute  purulent  bronchitis  occurred.  So  thick 
was  the  pus  that  pulmonary  abscess  was  feared.  Culture  showed  enorm- 
ous numbers  of  colon  bacilli  and  some  streptococci.  As  there  was  still 
some  expectoration  from  the  pneumonia,  the  author  believes  the  bron- 
chitis was  thus  directly  produced.  Beyond  the  initial  few  hours  there 
was  no  especial  discomfort  except  from  the  cough.  Autogenous  vaccines 
were  then  begun — 1,000,000,000  to  i  c.c.  One  minim  was  first  ad- 
ministered by  hypodermic,  and  this  continued  daily  for  several  days  and 
then  gradually  increased  by  >^-minim  doses  up  to  the  maximum, 
5  minims.  The  bronchitis  improved,  but  there  was  no  disappearance 
of  the  bacilli  from  the  urine,  though  the  vaccines  were  given  daily  by 
advice  of  the  pathologist.  At  the  end  of  May,  however,  the  general 
condition  of  the  patient  had  so  improved,  and  the  temperature  being 
generally  normal  the  greater  part  of  the  day  with  only  a  slight  evening 
rise,  that  he  was  removed  to  his  home.  At  the  end  of  three  weeks 
the  administration  of  vaccines  caused  a  marked  reaction,  so  they  were 
stopped. 

In  June  an  exacerbation  of  pyelitis  occurred  and  a  second  attack  of 
acute  colitis,  a  very  suggestive  coincidence.  Again  the  stool  was  examined 
for  pus  and  occult  blood,  as  ulcer  was  suspected  by  the  writer,  but  the 
results  were  negative.  The  author  is,  however,  fully  convinced  that  the 
colon  bacillus  infection  was  autogenous  from  the  gut.  A  thorough  in- 
vestigation was  made  at  the  time  of  the  catheterization,  and  no  flaw  in 
the  technic  could  be  detected.  The  subsequent  history  of  the  case  proved 
the  theory  auto-infective  process  to  be  correct. 

In  June  autogenous  vaccines  were  again  administered,  200,000,000, 
and  about  a  week  later  300,000,000.  Considerable  reaction  followed  these 
injections,  which  rather  alarmed  the  patient.  They  were  discontinued 
and  reliance  placed  on  the  hexamethylenamin  and  sodium  benzoate. 

In  early  June  the  patient  went  to  Williamstown,  at  this  time  there 
being  only  a  slight  evening  temperature,  99°  to  99.5°F.,  bacilluria  persist- 
ing, with  few  pus  cells.  There  was  still  a  slight  evidence  of  unresolved 
pneumonia  at  the  left  base,  but  no  cough.  The  patient  suffered  some 
shortness  of  breath  on  exertion,  and  the  heart  action  was  somewhat  rapid, 
a  myocarditis  of  mild  degree,  due  chiefly  to  the  toxemia  in  the  author's 
opinion.  In  early  July  the  writer  joined  the  patient,  and  twice  each 
week  the  urine  was  sent  to  New  York  and  examined  for  colon  bacilli. 

On  August  27th  the  colon  bacilli  disappeared,  there  being  only  a  few 
pus  cells  found  thereafter.  The  urine  remained  free  from  colon  bacilli 
until  October.  On  the  first  of  this  month  the  patient  returned  to  the 
Stock  Exchange  and,  against  advice,  persisted  in  a  full  day's  work.  On 
about  the  fourth  day,  he  had  slight  chilly  feelings,  slight  rise  of  tempera- 
ture, and  a  reappearance  of  the  colon  bacilli  in  the  urine,  though  not  in 
great  numbers. 

These  gradually  diminished  under  dosage  of  hexamethylenamin,  50  to 


INFECTIONS    BY    THE    BACILLUS    COLI  605 

60  grains  daily,  and  there  was  slight  evening  temperature  only  every  day 
or  two,  to  99°  to  99.5°F, 

William  H.  Thomson,  on  examining  the  case,  agreed  with  the  writer 
that  further  physical  rest  was  necessary.  He  also  held  that  the  infection 
undoubtedly  arose  from  the  intestinal  tract  through  some  undiscoverable 
lesion  in  the  intestinal  canal.  The  patient  was  sent  to  Europe  to  a  warm 
climate,  where  he  remained  until  May  i,  191 1.  He  continued  hexamethy- 
lenamin  about  40  grains  daily,  until  the  disappearance  of  the  colon  bacilli; 
thereafter  hexamethylenamin  15  grains  daily,  until  his  return. 

The  patient,  December  24,  1910,  wrote  me  that  his  temperature  re- 
mains normal,  and  only  a  few  colon  bacilli  persist  in  the  urine.  In  January, 
191 1,  the  colon  bacilli  entirely  disappeared  from  the  urine.  The  subse- 
quent course  of  this  case  is  of  considerable  interest.  From  January,  191 1, 
to  July,  of  the  same  year,  no  colon  bacilli  were  found  in  the  urine.  In 
May  the  patient  returned  to  the  Stock  Exchange.  In  July,  191 1,  an  attack 
of  acute  tonsillitis  occurred,  with  immediate  reappearance  of  colon  bacilli 
in  the  urine.  The  writer  was  absent  from  the  city,  and  the  physician 
in  attendance  did  not  examine  the  throat  discharge.  It  would  have 
proved  interesting  to  note  whether  an  exterior  reinfection  could  have 
occurred  through  the  tonsils.  From  January  to  May  i,  191 1,  the  patient 
had  continued  hexamethylenamin,  15  grains  daily  in  divided  doses,  as  a 
prophylactic,  and  thereafter  took  occasional  doses  up  to  the  time  of  re- 
currence. The  writer  advised  a  return  to  60  grains  of  hexamethylenamin 
a  day  at  this  time.  The  patient  rapidly  recovered  from  the  tonsillitis, 
felt  well,  and  in  about  a  week  resumed  business,  but  the  bacilluria  was 
still  present.  About  October  16,  191 1,  an  occasional  colon  bacillus  was 
found  in  the  urine,  though  the  patient  was  apparently  well.  Hexamethyl- 
enamin, 15  grains  daily,  was  still  continued.  The  case  is  particularly 
interesting  from  the  fact  of  recovery  from  apparently  what  was  believed 
to  be  a  fatal  infection  and  from  the  tendency  to  recurrence.  The  tendency 
to  chronicity  of  this  infection  is  undoubtedly  difficult  to  combat.  The 
patient  before  October  ist  had  regained  his  loss  of  weight,  which  was  35 
pounds.  Hexamethylenamin,  80  grains,  with  sodium  benzoate,  80  grains, 
were  given  daily  from  March  25th  to  June  ist,  1910.  From  June  ist  to 
July  9th,  he  averaged  60  grains  daily.  Up  to  May  ist  no  irritation  re- 
sulted from  the  treatment.  Sudden  changes  in  the  urinary  reaction  then 
occurred,  and  there  was  considerable  diflficulty  in  controlling  the  irrita- 
tion. It  would  be  extremely  acid  at  one  time  and  very  alkaline  later, 
both  conditions  causing  irritation.  The  writer  finally  secured  the  best 
results  keeping  the  urine  slightly  acid,  and  stopping  the  benzoate  when  a 
sudden  excessive  irritation  with  acidity  occurred,  and  then  giving  an 
alkali  (citrate  of  potash)  with  the  hexamethylenamin.  On  the  other  hand, 
when  the  urine  was  alkaline  with  irritation  from  too  much  alkali,  sodium 
benzoate  was  given  with  the  hexamethylenamin  and  the  potash  stopped. 
The  urine  was  carefully  watched  for  the  presence  of  casts  and  cylindroids, 
but  no  evidence  of  renal  irritation  from  the  hexamethylenamin  could  at 
9,ny  time  be  discovered.  From  July  7th  to  August  7th,  hexamethylena- 
min, 50  to  60  grains,  was  administered  daily. 

From  August  7th  to  October  4th,  1910,  hexamethylenamin  was  re- 


6o6  DISEASES    or    THE    STOMACH   AND   INTESTINES 

duced  to  40,  30,  and,  finally,  20  grains  daily,  the  latter  as  a  prophylactic 
as  the  colon  bacilli  disappeared  for  a  few  weeks.  In  spite  of  this  the 
colon  bacilli  reappeared  later  in  October. 

The  subsequent  course  of  this  patient  is  interesting  as  he  is  still  in 
June,  1916,  a  chronic  colon  bacillus  carrier.  From  January,  191 2,  to 
January,  1913,  the  colon  bacilli  in  the  urine  varied  for  a  few  thousand 
per  cubic  centimeter  to  as  many  as  100,000.  There  were  no  symptoms, 
and  only  occasionally  a  temperature  of  99°F.  The  patient  continued  his 
hexamethylenamin  40  to  60  grains  daily,  excepting  during  courses  of 
autogenous  vaccines  up  to  1,000,000,000  each  with  no  curative  results 
during  this  period. 

Vaccinations  alternating  with  hexamethylenamin  were  carried  out 
during  1914,  the  vaccines  being  pushed  to  1,800,000,000  on  one  occasion 
with  vomiting,  diarrhea,  and  acute  urinary  suppression  for  twenty-four 
hours  (anaphylaxis)  relieved  by  hypodermoclysis,  enteroclysis  at  i2o°F., 
etc.  subsequently  dependence  was  placed  on  the  hexamethylenamin. 
It  has  been  impossible  to  determine  in  this  patient  whether  the  source  of 
injection  lies  in  the  small  intestine,  large  intestine  or  rectum.  He  has 
been  a  chronic  colon  bacillus  carrier  for  six  years;  practically  since  his 
return  from  Europe,  May,  191 1,  he  has  attended  to  business  regularly 
and  has  rarely  had  even  a  slight  temperature.  On  the  occasion  of  his 
large  dose  of  vaccines  there  was  an  exacerbation  in  the  number  of  colon 
bacilli  in  the  urine  following  dietetic  indiscretions  and  intestinal  disturb- 
ance, in  addition  to  the  evident  anaphylaxis.  Excepting  during  the 
periods  of  vaccination  for  four  years  the  dosage  of  hexamethylenamin 
averaged  40  to  60  grains  daily,  usually  50  and  at  no  time  did  renal 
disturbance  result  from  the  drug.  For  the  past  two  years  he  has  taken  at 
times  from  15  to  30  to  40  grains  hexamethylenamin  daily,  varying  the 
dosage.  There  have  been  considerable  intervals  with  no  medication  but 
careful  diet.  He  feels  perfectly  well,  has  no  temperature  and  attends  to 
business  regularly.  With  even  acute  nephritis  from  colon  bacillus  infection, 
large  doses  even  80  grains  of  hexamethylenamin  can  be  given  daily,  with 
clearing  up  of  the  renal  congestion. 

On  the  other  hand  large  doses  of  this  drug  may  be  given  for  other 
conditions  and  cause  renal  congestion  which  immediately  disappears  on 
cessation  of  the  remedy,  particularly  if  cream  of  tartar  lemonade  is  also 
administered. 

It  was  interesting  to  note  that  the  30  grains  daily  of  the  drug  given  for 
the  initial  pyelitis  did  not  prevent  the  nearly  fatal  colon  bacillus  pneu- 
monia, and  that  the  large  doses  (80  grains  daily)  did  undoubtedly  pre- 
vent severe  symptoms  in  the  subsequent  second  pneumonia  and  purulent 
bronchitis.  The  autogenous  vaccination  evidently  was  of  some  value 
to  relieve  the  symptoms  of  the  bronchitis,  but  the  disappearance  of  the 
bacilli  only  occurred  following  the  persistent  use  of  hexamethylenamin. 
Hugh  Cabot^  has  shown  that  the  use  of  the  vaccines  is  followed  by  im- 
provement in  the  clinical  symptoms  in  one-half  the  cases,  but  that  they  have 
but  little  effect  on  the  bacteriuria. 

^  Amer.  Assoc-  of  Genito- Urinary  Surgeons,  Eighth  Congress  of  American  Physicians 
and  Surgeons,  igio. 


INFECTIONS   BY    THE   BACILLUS    COLI  607 

There  was  considerable  reaction  toward  the  end  of  the  first  period  of 
autogenous  vaccination,  and  marked  after  the  second.  The  patient, 
however,  is  a  chronic  carrier  apparently  immune  to  symptoms. 

Finally,  the  author  wishes  to  call  to  the  reader's  attention  that,  in 
addition  to  the  marked  indicanuria  in  intestinal  obstruction,  colon  bacilli 
infection  may  also  occur.  The  possibility  that  gastric  hemorrhage  as  a 
complication  of  acute  appendicitis,  may  be  the  result  of  colon  infection 
carried  to  the  stomach  producing  an  erosion,  is  worthy  of  investigation, 
especially  in  view  of  Tiirck's  experiments. 

Diagnosis. — Urine  should  be  examined  for  Gram-negative  bacilli 
(colon  bacilli),  and  then  cultures  should  be  grown;  the  sugar  fermentation 
test  is  also  of  value;  wound  infection  should  be  cultured,  and  also  the 
discharge  from  tumors  or  infected  wounds. 

Urine  Reaction. — With  colon  bacillus  infection  and  tubercle  infection 
the  urine  is  always  acid.  This  is  an  aid  to  diagnosis.  Other  types  of  pus 
in  the  urine,  with  pyelitis  or  cystitis,  give  an  alkaline  reaction  to  the  urine. 

Treatment  of  Infection  by  the  Colon  Bacillus. — Several  methods  have 
been  suggested;  first,  the  use  of  alkalies,  the  latter  being  pushed  so  that 
the  urine  becomes  strongly  alkaline,  the  claim  being  made  that  the  colon 
bacilli  do  not  propagate  in  an  alkaline  medium.  Alkalinity  of  the  blood 
is  also  increased. 

The  writer  has  not  been  successful  with  this  method. 

The  employment  of  hexamethylenamin  in  large  doses  in  association 
with  increased  acidification  of  the  blood  and  urine  (it  being  claimed  that 
hexamethylenamin  gives  off  formalin  best  under  these  conditions)  is  now 
advocated. 

Hinman^  has  demonstrated  that  hexamethylenamin  in  dosage  less 
than  45  grains  daily  has  no  antiseptic  value  and  to  produce  formaldehyd 
conversion  in  antiseptic  amounts,  the  urinary  acidity  should  be  greater 
than  2  c.c.  of  decinormal  sodium  hydrate  for  10  c.c.  of  urine. 

Acid  sodium  phosphate  (Merck's)  gr.  30  every  three  hours  three  to 
four  doses  daily  has  been  advised,  it  being  claimed,  as  noted,  that  the 
increased  acidity  renders  the  formaldehyd  more  active.  The  sodium 
phosphate  should  be  given  about  one  and  a  half  hours  before  the  hexa- 
methylenamin. 

The  writer  was  not  as  successful  with  this  as  with  the  sodium  benzoate 
in  most  of  his  cases. 

Sodium  benzoate  gr.  x  with  an  equal  dose  of  hexamethylenamin  has 
given  the  best  results  in  my  experience. 

The  employment  of  autogenous  vaccines,  or  irrigation  of  the  pelvis 
of  the  kidney  have  also  been  advised. 

KolP  and  others  recommend  irrigation  of  the  pelvis  of  the  kidney  with 
2  per  cent,  liquor  aluminium  acetate  in  colon  bacillus  pyelitis.  In  ascend- 
ing infection  it  might  be  of  value,  but  in  case  of  hematogenous  infection 
with  continued  reinfection  from  the  blood,  I  consider  it  useless.  Silver 
nitrate  i  :  20,000  to  i  :  10,000;  or  mercuric  oxycyanid  i :  10,000  to  i :  5,000 
have  also  been  advocated  for  pelvic  irrigation. 

'  Journal  A.  M.  A.,  Nov.  i,  1913. 
*Amer.  Jour.  Urology,  Nov.,  191 1. 


6o8  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

The  writer  recommends  (i)  hexamethylenamin  and  sodium  benzoate, 
each  lo  grains,  every  three  hours  by  mouth;  by  rectum,  if  there  is  vomiting 
or  coma.  After  prolonged  use,  if  excessive  acidity  with  irritation  occur, 
omit  the  benzoate  and  give,  with  the  hexamethylenamin,  potassium 
citrate;  thus  quickly  regulate  the  urine  so  as  to  lessen  acidity  but  not  suffi- 
cient to  make  it  continuously  neutral  or  alkaline.  Thomson  has  shown 
that  the  sodium  benzoate  augments  the  effects  of  the  hexamethylenamin. 
As  the  condition  improves  the  hexamethylenamin  and  sodium  benzoate 
may  be  gradually  reduced. 

(2)  Autogenous  vaccination,  especially  if  the  infection  is  chronic  or 
does  not  respond  to  treatment,  or  there  is  additional  infection  elsewhere, 
50,000,000  increasing  to  300,000,000  to  500,000,000  gradually,  first 
given  every  two  or  three  days;  larger  doses  at  longer  intervals,  four  to 
seven  days.  I  have  more  recently  used  up  to  i  ,000,000,000  to  i  ,800,000,000 
without  cure.     Some  advise  200,000,000,  increasing  to  1,000,000,000. 

(3)  Lactic  acid  bacilli  in  liquid  form  should  be  given  t.i.d.  Fair- 
child's  lactobacillin  or  any  reliable  preparation. 

(4)  High  enemata — i  :  1000  acetozone,  i  quart  every  day,  and  later 
every  other  day — are  of  value. 

(5)  Sour-milk  diet:  bacillac,  fermillac,  matzoon,  lactone-buttermilk, 
and  koumiss;  later,  cereals,  particularly  rice  grape  nuts,  etc.,  avoid  red 
meats. 

(6)  Bowels  should  be  opened  at  once  by  calomel  or  blue  mass,  followed 
by  a  saline  cathartic  and  then  regulated  carefully  daily.  Calomel  or 
blue  mass  once  a  week.  Russian  mineral  oil,^  olive  oil  by  mouth, 
agar-agar  (regulin),  purgen  and  cascara  are  an  aid. 

(7)  Antibacillus  coli  serum, ^  25  c.c.  in  divided  doses  in  three  days' 
time,  has  been  recommended. 

(8)  Surgical  procedure  when  indicated,  i.e.,  for  example  if  a  chronic 
infection  of  the  appendix,  or  rectal  ulcers  or  hemorrhoids  (ulcerated)  are 
deemed  responsible. 

^  American  mineral  oil  gss,  A.  M.  and  P.  M.  may  be  substituted. 
*  Rawls,  Med.   Rec,  Oct.   7,   1911. 


CHAPTER  XXIII 
CONSTIPATION  AND  DIARRHEA 

CONSTIPATION 

{Synonyms. — Obstipatio    Alvi;    Constipatio    Alvi;    Atony    of    the    Bowel;    Habitual 

Constipation) 

Healthy  persons  usually  have  one  bowel  movement  daily,  generally 
about  the  same  hour.  Some  normally  have  two  actions  a  day,  while 
others  empty  the  bowels  every  other  or  every  second  day,  and  yet  are 
in  perfect  health. 

Constipation  is  defined  as  a  condition  in  which  the  feces  are  not  passed 
sufficiently  often.  Another  form  is  that  in  which  defecation  occurs  daily, 
but  the  movements  are  insufficient  in  quantity.  A  stagnation  of  fecal 
matter  may  thus  occur.  The  quantity  of  feces  is  somewhat  variable, 
from  ICG  to  150  grams,  the  average,  even  up  to  250  grams,  being  greater 
after  a  vegetable  diet  and  less  after  meats. 

Considerable  of  the  evacuation  is  made  up  of  microorganisms,  of 
which  Herter^  has  estimated  the  daily  number  as  126,000,000,000,  which 
explains  the  fact  that  patients  who  eat  little  may  pass  considerable 
material. 

Constipation  may  be  acute  or  chronic.  The  acute  type  is  due  to 
complete  obstruction  of  the  intestinal  tract,  or  to  dynamic  ileus  (intestinal 
paresis). 

The  chronic  type  is  extremely  common.  Henry  lUoway  and  Samuel 
Gant  have  written  excellent  works  on  this  subject.  My  classification  is 
slightly  modified  from  their  books. 

Etiology. — All  possible  factors  must  be  carefully  investigated  and 
corrected. 

1.  Diseases  of  the  stomach,  such  as  hyperchlorhydria,  ulcer,  cancer, 
dilatation,  simple  atony,  catarrhal  conditions,  and  achylia  gastrica,  may 
cause  constipation. 

2.  Obstruction  oj  the  bowel  by  tumors  of  the  intestine  or  tumors  press- 
ing on  the  bowel  from  some  adjacent  organ;  by  stricture  within  the 
intestine;  by  external  stricture,  as  by  peritonitic  adhesions;  by  chronic 
intussusception. 

Lane  describes  a  type  of  chronic  obstruction  with  dilatation  of  the 
small  intestine,  including  the  duodenum,  due-  to  partial  obstruction  of 
the  termination  of  the  ileum  by  a  mesentery,  or  band  developed  in  the 
mesentery,  by  an  anchored  appendix  or  by  pressure  of  the  ileum  on  the 
pelvic  brim.  Mayo^  also  refers  to  cases  of  chronic  intestinal  stasis  due 
to  kinks  and  adhesions  of  the  terminal  ileum  (the  Lane  kink)  frequently 
associated  with  chronic  appendicitis, 

^  Bacterial  Infections  of  the  Digestive  Tract. 
^  Surgery,  Gynecology,  and  Obstetrics,  March,  191 1. 
39  609 


6lO  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

3.  Catarrh  of  the  small  intestine  alone;  in  some  cases  catarrh  of  the 
large  intestine:  mucous  colic;  atrophy  after  catarrh;  ulcers  of  the  small 
intestine  are  occasionally  attended  by  constipation;  dysenteric  ulcers  at 
times  produce  constipation,  though  ulcers  of  the  large  intestine  usually  cause 
diarrhea. 

4.  Voluntary  abstention  from  stool  on  account  of  the  pain  it  produces, 
by  reason  of  disease  of  the  rectum,  such  as  from  piles,  fissures,  or  ulcer. 
Increased  contraction  of  the  sphincter  ani  (irritability),  at  times  with 
resulting  h)^ertrophy,  also  occurs  from  irritation  and  interferes  with 
bowel  action.  Hypertrophied  levatores  ani  muscles  which  may  be  felt 
as  thick  rigid  bands  about  2  inches  above  the  anus  may  clamp  the  rectum 
and  interfere  with  bowel  movements. 

5.  Obstruction  to  the  entrance  of  bile  into  the  intestine  or  deficiency  of 
bile. 

6.  Diseases  of  the  heart,  lungs,  liver,  and  kidneys.  Intestinal  hyperemia 
and  congestion  of  the  portal  system  are  factors  in  these  cases  in  retarding 
peristalsis,  as  in  cirrhosis  of  the  liver. 

7.  Disease  of  the  pancreas. 

8.  Diabetes,  anemia,  and  chlorosis. 

9.  In  many  diseases  of  the  brain,  spinal  cord,  and  of  the  nervous  system 
constipation  is  present. 

Among  such  are  chronic  insanity,  diphtheritic  paralysis,  tabes,  brain 
tumors,  cerebrospinal  meningitis,  hemorrhage  of  the  brain,  chronic 
hydrocephalus,  myelitis,  neuroses,  and  psychoses. 

10.  Acute  febrile  conditions  are  usually  accompanied  by  constipation, 
as  pneumonia,  etc.  This  generally  excludes  those  with  special  intestinal 
lesions.  We  must  remember  that  constipation  occurs  in  some  cases  of 
typhoid,  and  even  of  dysentery. 

11.  Chronic  constipation  from  foreign  bodies.  They  may  be  lodged 
in  the  bowel  or  beneath  the  mucosa  and  either  obstruct  the  rectum  or 
cause  sphincteric  contraction. 

12.  Malformations,  such  as  abnormally  developed  or  dilated  colon; 
undue  size  or  length  of  the  sigmoid  flexure;  diverticula  of  the  large  intest- 
ine; a  diaphragm  partially  closing  the  large  intestine. 

13.  Defective  development  or  essential  primary  atrophy  of  the  colon. 

14.  Enter opto sis;  angulations  of  the  sigmoid  flexure  due  to  adhesions; 
prolapse  of  sigmoid  into  rectum  from  long  mesentery — in  effect,  slight 
intussusception;  cecum  mobile  (movable  cecum). 

15.  Atrophy  of  the  intestinal  musculature  following  catarrh  or  fatty 
degeneration,  as  in  consumption  or  in  alcoholics. 

16.  Hypertrophy  of  Houston's^  valves,  or  hypertrophied  O'Bierne's 
sphincter,  which  is  located  at  the  rectosigmoidal  juncture,  may  be  causes. 
Coccygeal  deviation  with  projection  inward  of  the  bone  may  be  a  factor. 

17.  Loss  of  power  in  the  abdominal  muscles  may  be  a  factor  in  some 
cases,  as  in  the  emaciated,  with  multiparous  women  with  diastasis  of  the 
recti,  etc. 

18.  Distention  of  the  duodenum  secondary  to  compression  or  obstruc- 
tion of  the  third  part  of  the  duodenum  by  reason  of  a  strain  exerted  on  it 

1  Gant,  N.  Y.  ^led.  Jour.,  April  15,  191 1. 


CONSTIPATION    AND    DIARRHEA  6ll 

by  the  mesentery  of  the  small  intestine  or  by  the  pull  on  it  by  the  jejunum. 
Some  of  these  cases  have  associated  a  duodenal  ulcer,  and  Lane'  describes 
a  case  in  which  there  was  torsion  at  the  duodeno-jejunal  junction,  the 
patient  being  a  sufferer  from  chronic  intestinal  stasis,  a  stenosis  of  the 
pylorus  being  suspected. 

19.  Chronic  constipation  from  impaired  physiologic  function.  This 
type  is  due  to  disturbance  of  the  motor  function  of  the  intestines,  and  is 
strictly  classified  under  motor  neuroses,  under  which  we  have: 

(fl)  Constipation  due  to  retarded  intestinal  peristalsis  (atony  or 
relaxation  of  the  bowel). 

(b)  Spastic  constipation,  perverted  action,  or  enterospasm.  The 
constipation  is  due  to  a  spasmodic  contraction  of  a  portion  of  the  intestine. 

(c)  Spasm  of  the  sphincter  is  included  under  this  type. 
Constipation  Due  to  Disturbances  of  the  Motor  Function. — Habitual 

constipation  due  to  impairment  of  the  physiologic  function  {i.e.,  caused 
by  motor  disturbances)  constitutes  an  important  class  of  cases.  It  should 
be  strictly  classified  under  motor  neuroses. 

There  are  the  two  types  mentioned  above:  the  atonic  and  the  spastic 
forms  of  constipation. 

Atonic  Constipation. — Constipation  due  to  atony  (literally,  relaxation) 
of  the  bowels  constitutes  the  majority  of  cases. 

Predisposing  Causes. — The  character  and  quantity  of  food  and  the 
amount  of  physical  exercise  influence  bowel  evacuation.  Boas  has  laid 
stress  upon  the  importance  of  the  type  of  nourishment  and  its  influence 
in  the  production  of  constipation  (alimentary  constipation). 

Albuminous  diet  consisting  of  meat  and  eggs  leaves  little  residue,  and 
eventually  tends  to  constipate;  while  with  vegetable  diet  there  is  more 
residue  and  the  fermentation  products  excite  peristalsis.  A  patient  may 
diet  by  avoiding  vegetables,  butter,  and  fat,  and  thus  constipation  result 
which  may  become  chronic. 

Repeated  neglect  of  the  call  of  nature  is  a  frequent  cause,  such  as  in  the 
case  of  young  girls  and  children  while  at  school,  or  among  women  at  social 
gatherings,  etc. 

Interruption  of  the  habit  of  regularity,  as  on  a  railroad  journey,  or 
an  attack  of  diarrhea  with  subsequent  constipation,  or  of  acute  fever, 
may  lead  to  habitual  constipation.  The  same  is  true  of  mental  condi- 
tions, such  as  depressing  emotions.  Prolonged  exercise,  such  as  long 
marches,  has  produced  chronic  constipation. 

Constipation  is  more  frequently  found  among  the  wealthy  than  among 
the  working  class.  The  mode  of  living,  sedentary  life,  etc.,  have  a  bear- 
ing. Worry  and  mental  strain  have  an  influence,  and  it  occurs  among 
neurasthenics  and  hypochondriacs. 

Habitual  constipation  is  found  in  those  engaged  in  active  exercise 
and  who  are  of  strong  constitution.  In  such  persons  the  cause  of  this 
perversion  of  motor  function  is  unknown,  but  it  seems  inherent  to  the 
patients  that  the  bowels  respond  slowly  to  stimuli.  In  some  cases  there 
seems  to  be  hereditary  or  congenital  diminution  of  intestinal  peristalsis 
(constipation). 

'  Surgery,  Gynecology,  and  Obstetrics,  March,  191 1. 


6l2  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Riegel  observed  cases  in  which  at  autopsy  the  musculature  of  the 
large  intestine  was  abnormally  thin  and  was  probably  congenital.  In 
some  of  these  cases  the  skeletal  muscles  were  strong.  Nothnagel  described 
similar  cases  in  which  the  general  muscular  development  was  poor.  These 
rare  conditions  cannot  be  recognized  intra  vitam. 

Enteroptosis  is  given  as  a  cause  of  chronic  constipation  on  account 
of  the  intestinal  angulation  which  occurs.  This  is  true  in  some  cases. 
The  general  atony^  with  enteroptosis  is  the  chief  factor.  The  musculature 
of  the  stomach,  intestines,  and  also  the  abdominal  muscles  are  relaxed, 
which  have  a  bearing  on  the  production  of  constipation.  The  abuse  of 
cathartics,  and  repeated  distention  of  the  bowel  from  large  enemata, 
may  produce  constipation. 

Spastic  Constipation. — Spasmodic  constipation  of  the  bowels,  or 
enterospasm,  is  produced  by  a  perversion  of  the  motor  function  of  the 
intestines,  taking  the  form  of  a  spasmodic  contraction  of  a  portion  of  the 
intestines,  which  may  involve  both  the  circular  and  longitudinal  muscles. 

This  spastic  condition  may  be  of  variable  duration  and  involve  dif- 
ferent segments  of  the  intestines.  Fleiner  holds  that  the  contracted 
portion  retains  its  contents,  while  others  believe  that  it  is  nearly  occluded 
by  the  spasm,  thus  creating  an  obstacle  to  the  passage  of  the  intestinal 
contents. 

Diffuse  enterospasm  involving  the  small  intestine  occurs  in  spinal 
meningitis,  in  diseases  of  the  pons  and  medulla,  and  in  chronic  lead- 
poisoning.     In  these  cases  the  abdomen  is  retracted  like  a  trough. 

Local  or  circumscribed  enterospasm  is  more  frequent,  and  it  gener- 
ally affects  a  portion  of  the  large  intestine.  The  abdomen  shows  no 
abnormality  on  inspection. 

Spastic  constipation  is  more  frequently  met  with  in  nervous  persons, 
neurasthenics,  the  hysteric,  and  in  those  debilitated  by  long-continued 
disease.  It  may  be  one  of  the  symptoms  of  vagotonia.  The  constipa- 
tion is  quite  obstinate,  lasting  for  several  days.  The  evacuation  is 
somewhat  painful  and  consists  of  small  balls  (goat  feces),  or  pencil-shaped 
fecal  material.  There  are  spasmodic  pains  in  the  left  lower  abdomen  or 
in  the  umbilical  region  which  are  relieved  by  the  passages. 

Spasm  oj  the  Sphincter  {Proctospasmus). — This  condition  really  be- 
longs to  spastic  constipation.  There  is  painful  spasmodic  contraction 
of  the  sphincter.  I  have  seen  cases,  however,  in  which  pain  was  not 
marked,  but  spasm  occurred  when  defecation  was  attempted;  in  effect, 
spasmodic  stricture  was  present.  Such  cases  may  be  a  direct  factor  in 
the  production  of  constipation. 

Many  cases  of  sphincteric  spasm  are  secondary  to  fissure  or  ulcer 
of  the  rectum,  or  are  reflex  when  there  are  inflammatory  conditions  in 
the  neighboring  organs,  such  as  the  uterus,  bladder,  etc.  Some  cases 
occur  as  a  primary  nervous  affection  and  are  chiefly  met  with  in  those 
with  a  nervous  taint  or  disease  of  the  spinal  cord. 

Rectal  examination  is  often  extremely  painful.  In  some  cases  there 
is  simply  reflex  spasm  on  examination,  and  the  sphincter  is  found  to  be 
extremely  tight  and  evidently  hypertrophied  from  frequent  contraction. 
*  Rose  and  Kemp,  Atonia  Gastrica. 


CONSTIPATION   AND   DIARRHEA  613 

It  is  important  to  consider  the  possibility  of  the  last  type  in  connection 
with  chronic  constipation. 

Symptoms. — In  many  cases,  constipation  causes  no  subjective  symp- 
toms. Some  have  a  stool  every  second  or  third  day  or  even  once  a 
week.  There  is  a  classical  case  who  had  an  annual  movement.  Never- 
theless, chronic  constipation  should  not  be  made  light  of. 

Constipation  may  be  accompanied  by  one  or  more  daily  stools  and 
even  by  diarrhea.  In  spite  of  a  daily  movement,  there  is  a  gradual 
accumulation  of  fecal  material,  and  great  rehef  is  afforded  by  a  cathartic. 
With  fecal  impaction  there  may  be  some  escape  of  material  around  or 
through  the  mass,  or  the  irritation  causes  some  diarrhea  at  times.  Boas 
describes  a  so-called  "fragmentary  constipation,"  in  which  condition 
there  is  a  conscious  feeling  of  feces  accumulated  in  the  rectum,  but  only 
occasional  fragments  escape  with  efiforts.  There  may  be  a  daily  movement, 
but  hard  masses  of  foul  odor,  are  evacuated. 

Some  patients  on  the  appearance  of  constipation  immediately  suffer 
from  subjective  symptoms,  which  may  become  at  times  quite  severe. 
Among  milder  symptoms  are  sensations  of  fulness,  tension,  and  discomfort 
in  the  abdomen;  at  times  they  are  referred  to  the  stomach;  loss  of  appetite, 
occasionally  belching,  nausea,  pyrosis,  and  a  disagreeable  taste  in  the 
mouth.  Coated  tongue  and  headache  are  often  present.  Colicky  pains 
and  distention  may  occur. 

Intestinal  Sapremia. — ^In  cases  of  marked  constipation  severe  symp- 
toms may  occur,  such  as  headache,  apathy,  a  dry  furred  tongue,  anorexia, 
prostration,  abdominal  pain,  sustained  elevation  of  temperature,  palpable 
spleen,  and  even  an  eruption,  so  that  typhoid  may  be  suspected.  The 
eruption  is  profuse  and  blotchy,  macular  and  erythematous,  and  not  likely 
to  be  mistaken  for  typhoid,  roseola,  or  Brill's  disease.  Physical  examina- 
tion will  determine  fecal  accumulation. 

These  symptoms  disappear  after  thorough  evacuation  of  the  bowels. 
In  cases  of  doubt,  such  as  intestinal  sapremia  of  a  duration  which  is  not 
definitely  obtainable,  it  may  be  advisable  to  make  the  laboratory  tests 
to  differentiate  from  typhoid  fever. 

On  inspection  and  palpation  considerable  fecal  accumulation  can  be 
found  in  the  intestines,  especially  in  the  colon.  Some  patients  suffer 
from  severe  headache,  dizziness,  sleeplessness,  despondency,  palpitation, 
tachycardia,  or  irregular  pulse.  Such  symptoms  I  believe  due  to  auto- 
intoxication from  the  intestinal  tract.  Motor  insufficiency,  as  in  consti- 
pation, favors  stagnation  and  putrefactive  changes. 

Duprey^  reports  extreme  cases  in  which  the  patients  become  uncon- 
scious, but  recovered  after  free  bowel  evacuation.  One  death  also 
occurred. 

In  most  of  my  patients  suffering  from  chronic  constipation,  with  the 
symptoms  just  described,  especially  with  nervous  manifestations,  marked 
indicanuria  was  present. 

Herter^  states  that  most  children  and  many  adults  may  fail  to  develop 

*  The  Lancet,  1902,  p.  1832. 

*  Bacterial  Infections  of  the  Digestive  Tract,  p.  263. 


6 14  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

indicanuria  with  constipation,  yet  there  are  others  in  whom  it  is  marked, 
and  that  a  satisfactory  explanation  is  not  possible. 

In  my  report  of  13  cases  of  dementia  paralytica  before  the  American 
Medicopsychologic  Association^  marked  constipation  was  noted  in  all 
the  cases,  and  all  suffered  with  considerable  temperature.  Rectal  irriga- 
tion lowered  the  temperature  in  three  cases,  and  under  general  treatment 
for  the  gastro-intestinal  tract  it  was  lowered  in  eight  more.  Convulsions 
diminished  in  five  cases.     The  bowels  were  freely  opened. 

Bouchard's  theory,  that  no  intoxication  from  the  intestinal  tract  can 
take  place  when  the  feces  are  solid,  I  beheve  untenable.  Dunin  has  shown 
that  constipation  may  be  the  result  of  nervous  conditions.  There  are 
many  in  which  no  nervous  factor  can  be  discovered,  and  others  in  whom 
constipation  and  intestinal  auto-intoxication  are  factors  in  the  production 
of  nervous  symptoms. 

Termination. — The  bowels  may  act  spontaneously,  hard  masses  of 
fecal  matter  being  passed,  covered  with  a  thin  layer  of  mucus.  Feces 
are  often  passed  in  small  balls,  or  in  rod  shape.  With  the  atonic  type 
of  constipation  relief  is  usually  felt  after  defecation,  while  with  the 
spastic  type  movement  is  accomplished  with  great  effort,  and  there  is  a 
feeling  as  if  there  were  still  material  in  the  rectum. 

In  some  cases  the  constipation  terminates  in  an  attack  of  diarrhea, 
due  to  hyperemia  and  the  secretion  of  fluid  from  irritation  of  the  mucosa 
by  the  hardened  feces.  In  others,  purgatives  or  enemata  may  be  required, 
or  removal  of  scybalae  from  the  rectum  by  the  fingers. 

Slight  catarrh  may  occur  or,  rarely,  stercoral  ulcers,  local  peritonitis, 
or  even  perforation  and  general  peritonitis.  Constipation  has  been  a 
factor  in  the  production  of  typhlitis,  diverticulitis,  catarrh  of  the  cecum 
with  secondary  catarrhal  appendicitis,  volvulus,  and  subacute  or  acute 
intestinal  obstruction. 

Fecal  Colic. — When  large  masses  of  fecal  matter  accumulate  colic 
may  occur.  The  patient  is  seized  with  violent  colicky  pains  which  may 
cause  a  fainting  spell.  The  abdomen  is  distended  and  tender.  Passage 
of  flatus  brings  temporary  relief.  Th&  symptoms  do  not  disappear  until 
thorough  evacuation  of  the  fecal  accumulation  takes  place.  Fecal  colic 
may  occur,  with  daily  evacuation  of  the  bowels.  The  detection  of  fecal 
accumulation  by  palpation  is  of  chief  importance. 

In  obstinate  cases  of  constipation  cathartics  may  fail  to  produce 
movements  and  the  patient  go  into  marked  collapse  and  vomit  profusely, 
with  symptoms  resembling  intestinal  obstruction.  Rectal  irrigations  or 
oil  injections  may  relieve  the  condition. 

Rarely,  in  the  insane,  old,  or  weak,  total  paralysis  of  the  colon  may 
take  place  and  the  patient  die  with  the  symptoms  of  obstruction.  In 
cases  of  fecal  accumulation,  it  is  always  safer  to  employ  injections  and 
irrigations  before  resorting  to  active  catharsis. 

Fecal  Tumors. — They  occur  most  frequently  in  the  cecum,  sigmoid 
flexure,  rectum,  and  hepatic  and  splenic  flexures.  They  may  cause  dis- 
location of  the  transverse  colon,  and  the  mass  be  felt  a  short  distance  above 

^  Proceedings  of  the  Sixty-first  Annual  Meeting,  April,  1903.  Some  observations 
on  the  Relations  of  the  Gastro-intestinal  Tract  to  Nervous  and  Mental  Diseases. 


CONSTIPATION    AND    DIARRHEA  615 

the  symphysis.  In  most  cases  the  tumor  is  not  of  very  firm  consistency, 
is  movable,  and  pits  on  pressure.  On  the  other  hand,  it  may  be  nodular, 
hard,  or  angular. 

In  some  cases  the  bowels  may  move  every  day,  there  evidently  being 
a  free  central  passage. 

Gersuny^s  Adhesion  Symptom. — ^If  the  abdominal  wall  over  the  tumoj 
is  gradually  depressed  with  the  finger-tips,  the  pressure  gradually  dimin- 
ished and  the  fingers  slowly  withdrawn,  one  can  feel  the  mucous  coat  of 
the  intestines  loosening  itself  from  the  feces  forming  the  tumor  (i.e.,  the 
wall  of  the  bowel  separates  from  the  tumor  when  palpating  pressure  is 
relaxed). 

If  under  intestinal  irrigations,  etc.,  the  tumor  diminishes  in  size,  it 
is  evidently  fecal.     Anesthesia  may  rarely  be  required  for  examination. 

Some  of  these  fecal  tumors  have  developed  into  large  size — over 
4  pounds  or  more — and  after  the  colon  is  dilated,  stercoral  ulcers,  local 
or  general  peritonitis,  or  intestinal  obstruction  from  kinking,  compression, 
torsion,  or  internal  occlusion  may  result. 

Hemorrhoids  are  a  complication.   They  are  described  in  a  special  section. 

I  have  referred  to  various  nervous  symptoms  that  are  dependent  on 
constipation. 

Leube  describes  intestinal  vertigo,  which  he  believes  reflex  and  due 
to  pressure  on  the  hemorrhoidal  plexuses  of  the  sympathetic,  since  the 
palpating  finger  in  the  rectum  also  produced  it. 

Senator  imputed  dizziness  and  vertigo  to  absorption  of  poisonous 
gases,  such  as  sulphuretted  hydrogen;  while  Nothnagel  assumes  that 
nervous  symptoms  are  due  to  absorption  of  ptomains,  thus  causing  auto- 
intoxication. 

Auto-intoxication  I  believe  to  be  the  correct  explanation.  In  persons 
of  a  neuropathic  disposition  auto-intoxication  (intestinal  toxemia)  from 
chronic  constipation  is  undoubtedly  a  contributory  factor  in  the  produc- 
tion of  nervous  disease,  especially  melancholia.  It  is  also  evidenced  by 
indicanuria. 

Fecal  Fever. — This  is  generally  due  to  some  complication,  such  as 
inflammation,  local  peritonitis,  or  stercoral  ulcer.  With  infants  and 
young  children  fever  may  be  caused  by  fecal  accumulation.  I  have 
referred  to  the  cases  of  dementia  paralytica  with  temperature,  with 
disappearance  of  the  latter  after  bowel  action. 

Clark  holds  that  chlorosis  is  the  result  of  toxins  absorbed  from  copro- 
stasis.  Hyperchlorhydria  is  generally  present  and  this  would  have  an 
influence  on  the  bowels. 

Though  diarrhea  with  marked  multiplication  of  the  Bacillus  aerogenes 
capsulatus  often  occurs  in  common  with  severe  primary  anemia,  and 
in  some  instances  the  cases  present  the  blood-picture  and  clinical  character- 
istics of  pernicious  anemia,  yet  Herter  shows  that  advanced  infection  with 
the  gas  bacillus  can  occur^  without  any  diarrhea,  in  farct,  with  obstinate 
constipation.  Stasis  is  favorable  to  putrefaction.  The  possibility,  there- 
fore, of  stasis  (constipation)  favoring  in  some  cases  the  development  of 
poisons  having  a  hemolytic  action  on  the  blood  should  be  considered. 
'  Bacterial  Infections  of  the  Digestive  Tract,  p.  207. 


6l6  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

Diagnosis. — The  irregularity  of  the  movements  and  their  character, 
occurring  in  small  balls,  pencil  shape,  or  in  small  fragments,  and  ab- 
dominal palpation,  disclosing  fecal  masses,  are  diagnostic.  One  must 
remember  that  daily  incomplete  evacuations  may  occur. 

Fecal  masses  are  found  most  frequently  in  the  captU  coli,  sigmoid, 
and  the  rectum.  It  is  always  well  to  examine  the  latter.  All  possible 
causes  of  constipation  must  be  considered.  If  it  is  suspected  to  be  due  to 
anomalies  of  the  functions  of  the  stomach,  gastric  analysis  must  be 
performed  and  treatment  directed  toward  the  gastric  condition. 

Diseases  of  the  heart,  lung,  Hver,  and  kidneys  must  be  treated  if 
present.  Rectal  examination  may  disclose  hypertrophy  of  Houston's 
valves;  in  such  event,  their  division  by  the  application  of  Gant's  valve 
clamps  is  indicated.  Hemorrhoids  must  be  removed,  also  polypi  if  present, 
or  tumors.  If  adhesions  are  a  cause,  they  must  be  severed  or  released 
from  the  gut.     Hernia  if  a  factor  must  be  operated  upon. 

Prolapse  of  the  sigmoid  may  be  determined  by  inspection  with  the 
sigmoidoscope.^  Gant's  suspensory  operation  is  then  indicated.  Splanch- 
noptosis if  present  must  be  treated  and  Rose's  belt  applied.  Intestinal 
stasis  due  to  Lane's  kinks,  adhesions,  angulations,  dilated  duodenum,  mov- 
able cecum  and  patent  ileocecal  valve  will  be  described  in  a  special  chapter. 

If  none  of  these  causes  can  be  determined,  the  constipation  must 
be  purely  functional  (habitual),  either  of  the  atonic  or  spastic  type. 

With  atony  of  the  bowels  there  are  sHght  bloating,  evacuation  of  hard 
fecal  matter,  often  in  balls  covered  with  a  thin  layer  of  mucus,  at  times 
dizziness  and  nervous  symptoms.     Severe  pains  are  rare. 

With  enterospasm  there  are  uneasiness  and  pain  at  the  time  of  evacua- 
tion or  just  preceding  it,  and  at  times  spells  of  faintness.  The  fecal 
matter  is  not  so  hard  and  is  evacuated  after  considerable  straining  in 
narrow,  tape-like  or  pencil-shaped  pieces.  There  is  no  feeling  of  complete 
relief  after  evacuation,  but  as  if  more  were  present.  The  abdomen  may 
at  times  be  sunken  and  retracted  and  the  intestinal  coils  can  sometimes 
be  palpated. 

Prognosis. — This  is  favorable  in  the  majority  of  cases  as  regards  life, 
though  occasionally  incurable  lesions,  such  as  diverticulitis,  ulceration, 
or  even  peritonitis  and  death  may  result.  These  complications  are 
comparatively  rare.  The  prognosis  as  to  cure  depends  on  the  cause  of 
the  constipation.  In  the  functional  cases  of  habitual  constipation  cures 
result,  but  many  cases  require  more  or  less  care  for  the  balance  of  their  lives. 

Treatment. — General  Methods. — The  cause  of  the  constipation  should 
be  diagnosed  and  treated.  This  has  been  referred  to  under  diagnosis. 
Having  excluded  all  causes  but  the  atonic  or  spastic  types,  they  should 
receive  treatment  as  follows:  Persons  who  for  years  have  habitually 
had  a  movement  every  second  or  third  day  and  are  in  good  health 
should  be  let  alone. 

Prophylaxis. — Never  place  a  patient  on  a  restricted  diet  for  too  long 
a  period,  excluding  vegetables,  fruits,  starchy  foods,  and  fats  which  would 
dispose  to  constipation.     Abuse  of  cathartics  should  be  avoided. 

1  The  a;-rays  will  also  determine  prolapse  of  the  sigmoid  or  other  portions  of  the 
large  intestine. 


CONSTIPATION   AND    DIARRHEA  617 

A  hygienic  method  of  Hving,  proper  out-of-door  life  and  exercise, 
diminution  of  strain  and  worry  are  necessary.  As  few  purgatives  as 
possible  should  be  employed. 

Training  of  the  Patient. — One  should  allay  the  patient's  anxiety. 
He  should  be  told  not  to  worry  if  the  bowels  fail  to  act  for  a  day  or  two. 
Meanwhile,  rational  methods  should  be  undertaken  by  the  physician  to 
produce  the  desired  result.  Trousseau  first  advocated  teaching  regularity. 
The  patient  should  be  taught  to  endeavor  to  have  an  evacuation  at  a 
regular  time  every  day,  preferably  half  an  hour  after  breakfast.  He  should 
go  to  the  closet  and  try  to  have  a  passage,  but  should  not  exert  himself 
for  over  five  minutes.  It  is  an  excellent  procedure  to  aid  the  return  to 
the  habit,  by  insertion  of  a  small  gluten  or  glycerin  suppository  or,  pref- 
erably, the  injection  of  i  to  2  ounces  (30.0-60.0)  of  olive  oil  with  a  soft- 
rubber  hand  syringe.  This  is  better  than  waiting  twenty-four  hours,  as 
the  desire  is  often  thus  stimulated.  Regular  habits  could  thus  often  be 
cultivated  and  the  small  injection  then  stopped. 

Diet. — The  main  object  is  the  ingestion  of  foods  which  increase 
intestinal  peristalsis  and  the  avoidance  of  constipating  material. 

A  glass  of  cold  water,  or,  in  some  cases,  of  hot  water,  should  be  taken 
on  rising.  Water  should  be  taken  on  the  fasting  stomach  and  a  moderate 
amount — 8  to  10  ounces  (250-310  c.c.)  at  least — of  fluid  at  meals.  Total 
abstinence  from  liquid  at  meals  tends  to  constipate.  The  following  are 
of  value,  buttermilk,  cider,  sour  milks,  fermented  milk,  such  as  lactone- 
milk,  koumiss,  matzoon,  bacillac,  fermillac,  carbonated  waters;  raw  fruits, 
such  as  grapes,  oranges,  grape-fruit,  apples,  figs,  prunes,  cranberries,  pears, 
peaches,  plums,  mandarins,  gooseberries,  currents,  strawberries,  rasp- 
berries, blackberries;  cooked  fruits,  jams,  treacle,  honey,  lemonade;  vege- 
tables rich  in  cellulose,  cabbage,  cucumbers,  spinach,  green  peas,  Brussels 
sprouts,  cauliflower,  green  salads,  turnip  tops,  Spanish  onions,  carrots, 
asparagus;  syrup,  sugar;  salmon,  sardines,  herring;  rye  bread,^  Graham 
bread,  pumper-nickel;  fatty  and  highly  seasoned  foods,  plenty  of  butter, 
cream,  and  fat  cheese.  Excess  of  potatoes  or  rice  constipate.  Oatmeal 
is  often  of  value.  Milk  is  constipating  with  some  and  purgative  with 
others.  Whortleberries  are  constipating.  Red  wines,  tea,  chocolate, 
and  cocoa  should  be  avoided.  Beer  and  champagne  are  recommended 
by  some.     Chicken  and  red  meats  are  given  in  moderation. 

We  may  say  the  diet  should  be  mixed,  with  a  preponderance  of  vege- 
table food.  Some  patients,  of  course,  have  idiosyncrasies  to  certain 
foods,  and  one  would  not  give  a  patient,  with  a  delicate  stomach,  cabbage, 
cider,  and  brown  bread.  If  the  intestines  are  already  overburdened  with 
too  much  ballast  and  excess  of  cellulose  has  been  given,  such  articles  must 
be  restricted. 

The  internal  administration  of  olive  oil,  i  to  2  ounces  (30.0-60.0)  or 
more,  has  often  an  excellent  effect;  to  be  given  once  or  thrice  daily. 

If  fermentative  or  putrefactive  processes  are  present,  they  must  receive 
attention. 

In  very  obese  patients,  one  would  not  give  excessively  fattening  food. 
Often  a  few  prunes  with  the  morning  glass  of  water  and  fruit  for  breakfast 
'  Whole  wheat  bread  and  bran  biscuits  are  of  value. 


6l8  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

are  serviceable.  The  administration  of  a  raw  apple  thoroughly  masti- 
cated at  9  P.  M.  and  an  hour  later  a  large  glass  of  Vichy,  I  have  often 
found  valuable,  a  morning  movement  resulting. 

As  a  sample  diet  one  may  give  as  follows: 

Breakfast. — Oatmeal  with  cream  or  porridge  with  syrup,  fat  bacon, 
rye  bread  with  plenty  of  butter,  marmalade  or  honey,  coffee  with  cream, 
water  8  ounces  (250  c.c.)  grape-fruit  or  oranges.  •  Grape  nuts,  which  are 
twice  baked  and  contain  whole  wheat,  are  a  cheap  cereal  and  are  of  some 
value  to  aid  bowel  action. 

Lunch. — Fish,  potatoes  (very  little),  green  vegetables,  salad  with 
plenty  of  oil,  stewed  apples  or  figs,  wholemeal  bread,  butter,  fruit,  water, 
or  lemonade. 

Dinner. — Tomato  or  some  vegetable  soup,  meat,  spinach,  string-beans, 
asparagus,  salad  with  oil,  dry  toast  or  biscuit  with  plenty  of  butter,  apple 
charlotte,  stewed  pears  or  prunes,  cheese,  uncooked  fruits,  water  or 
lemonade. 

Whole  wheat  biscuit  which  contain  phytin  (a  laxative);  bran  biscuit 


Fig.  283. — Cannon-ball  with  screw  cap.       Fig.  284. — Cannon-ball  with  handle. 

(well  dried),  the  bran  having  a  mechanical  effect,  and  the  whole  wheat 
ingredients  containing  phytin,  are  an  excellent  addition  to  the  dietary. 

Physical  Methods.— These  are  useful  to  strengthen  the  bowel  and 
promote  better  action  or  to  directly  stimulate  peristalsis. 

Massage. — This  is  of  use  in  the  atonic  cases,  but  not  as  much  so  in 
spastic  constipation.  It  should,  preferably,  be  administered  by  an  expert 
and  the  treatment  carried  out  for  many  months. 

Abdominal  massage  should  be  carried  out  in  the  course  of  the  colon 
by  short  tapping  motions  (vibratory),  or  by  kneading  and  rubbing.  It 
is  preferable  to  massage  from  the  caput  coli  to  the  sigmoid.  The  small 
intestine  should  also  be  manipulated  as  well  as  the  abdominal  muscles. 

Illoway,^  recommends  massage  for  five  to  fifteen  minutes  in  adults 
and  three  to  five  minutes  for  children,  at  least  every  other  day,  for  a 
period  of  six  weeks,  and  then,  if  there  is  improvement,  at  longer  intervals, 
1  Constipation  in   Adults  and   Children. 


CONSTIPATION    AND    DIARRHEA  619 

but  for  a  long  period  of  time.     It  should  be  given  preferably  early  in  the 
morning  in  the  fasting  condition. 

Aiitomassage. — The  patient  sitting  upright  with  the  right  hand  should 
stroke  the  abdomen  from  the  caput  coli  to  the  hepatic  flexure,  and  then 
along  the  transverse  colon.  With  the  left  hand  he  can  then  massage 
down  the  descending  colon.  Circular  stroking  movements  should  then 
be  made  over  the  median  abdominal  region.  I  often  have  the  patient 
follow  this  out  while  endeavoring  to  have  the  morning  defecation. 
Seances  should  last  about  five  to  ten  minutes. 

Cannon-hall  Massage. — A  3-  to  5-pound  cannon-ball  rolled  over  the 
abdomen  in  the  course  of  the  colon  and  small  intestine  spirally  is  of  value. 
The  patient  can  employ  this  in  the  dorsal  position. 

The  hollow  wooden  cannon-ball  with  a  screw-cap,  arranged  so  that 
shot  can  be  placed  thereirt,  and  thus  different  weights  employed  with  the 
same  ball,  is  an  excellent  instrument  (Fig.  283).  It  is  arranged  with  a 
handle  and  frame  so  that  it  can  be  more  easily  manipulated  (Fig.  284). 
One  should  begin  with  a  weight  of  2  pounds  and  increase  it  gradually  to 
5  pounds. 

Vibratory  Massage. — This  is  of  great  value.  Special  vibration  should 
be  given  over  the  sigmoid  flexure.  The  Vedee  vibrator  can  be  used  alone 
or  with  electricity,  or  the  Eureka  or  any  good  electric  vibrator  can  be 
attached  to  the  street  current.  Seances  should  last  about  ten  to  fifteen 
minutes  in  the  course  of  the  colon  and  over  the  small  intestine. 

Hot  and  Cold  Massage  Electric  Roller. — This  instrument  has  been 
described  and  can  be  employed  for  the  atonic  cases. 

Gymnastic  Exercises. — Exercises  which  bring  the  abdominal  muscles 
into  play  are  of  value,  such  as  gymnastics  on  the  horizontal  bar,  horse- 
back riding,  hill  climbing,  skating,  rowing,  bicycling,  golf,  tennis,  boxing, 
fencing.  Overexertion  and  too  abundant  sweating  should  be  avoided. 
Flexion  and  extension  of  the  body  and  lateral  rotation  while  in  the  sitting 
posture;  bending  downward  and  then  upward  in  the  standing  position  with 
the  knees  held  stiff;  attempting  to  touch  the  floor — about  25  to  5c 
times  morning  and  night;  lying  on  the  back  and  raising  the  legs  one  after 
another  with  the  knee  stiff  and  the  thigh  at  right  angles  to  the  body; 
Swedish  movements  and  treatment  by  the  Zander  methods  are  all  of 
value. 

Electricity. — Percutaneous  electricity,  especially  faradization  over  the 
abdomen,  is  useful  as  an  adjunct.  The  intrarectal  method  (one  electrode 
in  the  rectum  and  the  other  over  the  abdomen)  is  recommended,  especially 
galvanization. 

The  author's  method  with  recurrent  electric  irrigation  is  practical.  With 
a  glass  Y  attachment  and  two  fountain  syringes,  alternate  hot  and  cold 
electric  douches  can  be  employed  for  the  atonic  condition.  I  have  used 
both  the  faradic  and  galvanic  current.  In  obstinate  cases  of  high  im- 
paction I  have  found  hot  normal  saline  douches  at  1 2o°F.  with  the  faradic 
current  most  efficacious,  duration  fifteen  to  thirty  minutes. 

Kussmaul  has  suggested  one  electrode  in  the  stomach  and  the  other 
in  the  rectum. 

Electricitv  is  indicated  in  the  atonic  cases.     Static  electricitv  is  also 


620  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

recommended.  Doumer^  has  employed  it  in  the  form  of  sparks,  especially 
in  the  left  iliac  fossa. 

Hydrotherapy. — Frictions,  cold  douches,  the  alternating  cold  and  warm 
fan  douches,  Scotch  douches,  short  cold  sitz-baths  (five  minutes  at  i2°C.), 
the  wet  binder  (Neptune's  girdle)  applied  over  night,  and  the  Priessnitz 
compress  are  all  recommended.  Hydrotherapy  must  needs  be  conducted 
at  a  sanatorium. 

For  practical  purposes  the  sitz-bath  and  wet  abdominal  compress 
sufl&ce  the  general  practitioner. 

Injections;  Enteroclysis. — Recurrent  enteroclysis  with  hot  normal 
saline  solution  at  iio°  to  i2o°F.  for  fifteen  minutes  three  times  a  week, 
alone  or  combined  with  electricity  (rectal  method)  or  with  the  alternating 
cold  douche  at  6o°F.,  may  prove  of  service  in  the  very  obstinate  cases. 

Enteroclysis  with  flaxseed  tea  has  also  proved  valuable. 

The  soapsuds  and  water  enema  alone — i  pint  to  ij^  quarts  (500- 
1500  c.c.) — or  with  live  oil,  8  ounces  (250  c.c),  or  castor  oil,  i  to  2  ounces 
(30.0-60.0),  included,  or  normal  salt  solution  alone,  may  be  required, 
depending  on  the  conditions.  A  high  enema  of  olive  oil,  8  ounces  (250 
c.c),  combined  with  glycerin,  4  ounces  (125  c.c),  is  often  useful.  Alum 
5i-3ii  to  the  pint  of  hot  water,  a  quart  enema  is  efficacious  in  some 
obstinate  cases. 

Often  a  small  enema  of  normal  saline  or  soapsuds  and  water  of  i  pint 
(500  c.c),  if  given  with  the  patient  in  the  knee-chest  position  is  more 
efficacious  than  the  larger  injections.  The  water  injections  may  be 
employed  at  the  same  hour  daily  for  a  considerable  time.  The  large 
injections,  as  recommended  by  some,  overdistend  the  already  atonic 
intestines.     The  Sims'  position  is  excellent  for  the  injection. 

EJemperer^  recommends  the  injection  into  the  bowel  of  small  quantities 
of  water  at  bedtime — only  }i  pint  (250  c.c) — and  the  patient  is  told  to 
retain  the  fluid.  It  is  soon  absorbed  and  evacuation  occurs  the  follow- 
ing morning.  These  injections  are  given  every  night  for  three  weeks, 
and  then  every  other  night. 

Kussmaul  and  Fleiner  employ  an  injection  of  sweet  oil  into  the  rectum 
at  bedtime,  which  is  to  be  retained.  I  believe  it  advisable  to  start  with 
a  small  quantity,  only  4  to  6  ounces  (125.0-200.0),  heated  to  the  tempera- 
ture of  the  body  and  slowly  injected  through  a  colon-tube  from  a  fountain 
syringe.  The  patient  should  retain  the  oil  as  long  as  possible  (over  night 
if  he  can).  Gradually  increase  the  quantity  to  8  ounces  to  i  pint  (250- 
500  c.c),  and  in  obstinate  cases  nearly  to  i  quart  (liter). 

As  a  rule,  evacuation  follows  the  next  morning.  I  give  the  injection 
every  night  for  a  week,  then  every  other  night  for  several  weeks,  then 
twice  a  week,  and,  finally,  once  a  week.  The  treatment  should  cover 
several  months.  This  method  is  recommended  especially  for  the  spastic 
type  of  constipation,  but  I  have  found  it  of  value  in  other  cases.  Aromatic 
liquid  albolene — a  refined  Russian  petroleum — is  also  useful  but  is  more 
expensive. 

Olive  oil,  I  to  2  ounces  (30.0-60.0),  by  mouth  once  to  three  times  a 

^  Annales  d'Electro-Biologie,  1898,  p.  722. 
*  Therapie  der  Gegenwart,  1899,  p.  48. 


CONSTIPATION    AND    DIARRHEA  62 1 

day  is  a  valuable  adjunct.  Cottonseed  oil  can  be  substituted  by  enema  for 
olive  oil,  it  is  much  cheaper. 

Glycerin  Injections. — Glycerin,  i  to  2  drams  (4.0-8.0),  dissolved  in  3 
ounces  (95.0)  of  water  and  injected  into  the  rectum  is  of  service  in  some 
cases,  or  given  as  a  suppository.     It  is  sometimes  irritating. 

Flatau^  inserts  or  insufflates  into  the  rectum  15  to  45  grains  (1.0-3,0) 
of  boric  acid  powder.     Bowel  action  results  one-half  to  three  hours  later. 

Orthopedics. — I  have  found  Rose's  belt  of  value  in  chronic  atonic 
constipation,  even  if  no  ptosis  is  present.  It  lends  strength  to  the 
abdominal  muscles  and  so  aids  evacuation. 

Medication. — In  many  cases  of  constipation  mild  laxatives  must  be 
employed,  sometimes  only  temporarily.  More  powerful  cathartics  are 
often  required.  In  constipation  of  the  spastic  form  due  to  vagotonia  and 
in  the  atonic  type  with  fecal  impaction,  belladonna  is  of  great  value.  It 
should  be  given  preferably  as  atropin  gr.  Koo  to  gr.  ]4q  t.i.d.,  or  tinct. 
belladonna  gtts.  x-xv  t.i.d. 

The  writer  finds  olive  oil  from  3i  to  5ss,  floated  on  a  little  water,  and 
taken  in  association  with  a  pinch  of  salt,  three  times  daily  after  meals 
an  excellent  adjunct.  This  seems  to  eliminate  the  taste  of  sweet  oil,  to 
which  some  object;  Russian  mineral  oil  one  tablespoon  (5ss)  A.  m.  and 
p.  M.  is  of  service.  Aromatic  liquid  albolene,  a  highly  refined  Russian 
petroleum,  American  mineral  oil,  or  even  white  vaselin  can  be  substituted 
in  doses  of  5i  to  5ss  t.i.d. 

The  author  generally  starts  the  treatment  with  laxatives,  training  the 
patient  as  to  regular  habits,  exercise,  auto-massage,  agar-agar  at  meals 
Russian  oil  A.  m.  and  p.  m.,  or  olive  oil  after  meals  in  addition.  Occa- 
sionally the  tincture  of  belladonna  may  be  used  in  large  doses,  10  to  15 
minims  (0.592-0.888  c.c),  and  pushed  three  or  four  times  a  day,  so  that 
physiologic  symptoms  are  apparent.  In  constipation  due  to  atony, 
strychnin,  ^oo  to  >^o  grain  (0.00108-0.0021)  t.i.d.,  or  tincture  of  nux 
vomica  in  5-  to  lo-drop  doses  are  of  value,  even  if  no  laxatives  are  given. 
They  are  often  combined  with  a  laxative. 

Among  the  milder  laxatives  are  fluidextract  of  cascara  sagrada  and 
the  aromatic  fluidextract  of  cascara,  of  which  the  dose  is  i  to  2  drams 
(4.0-8.0);  extract  of  cascara,  i  to  5  grains  (0.065-0.0324);  laxophen,  a 
solution  of  phenolphthalein,  i  to  4  drams  (4.0-16.0);  phenolphthalein 
(purgen),^  i  to  5  grains  (0.065-0.324)  to  15  grains  (i.o);  phenolax  (i  to 
3  wafers);  phenolphthalein  may  be  given  in  capsules  i  to  5  grains  each 
at  bedtime  or  even  t.i.d.;  purgatin,  15  to  30  grains  (1.0-2.0),  which  last 
is  contraindicated  in  renal  disease. 

Ad.  Schmidt^  claims  that  the  internal  administration  of  agar-agar, 
cutting  up  the  straws  into  small  fragments  and  administering  as  much 
as  25.0  grams  a  day,  aids  in  softening  the  feces  and  also  evacuation.  He 
adds  to  it  25  per  cent,  of  an  aqueous  extract  of  cascara  sagrada.  Schmidt 
recommends  this  combination,  which  is  dispensed  as  "Regulin,"  as  being 
of  value  in  chronic  constipation.     Dose,  i  teaspoonful  (4.0)  to  a  table- 

^  Berlin,  klin.  Wochenschr.,  1891,  p.  231. 

*  Purgen  tablets  (Bayer),  each  tablet  contains  iH  grains  (o.i)  of  phenolphthalein; 
each  phenolax  wafer  contains  i  gr.  of  the  same. 
'  Miinchener  med.  Wochenschr.,  No.  41,  1903. 


622  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

spoonful  (16.0)  or  more,  mixed  with  stewed  apples  or  mashed  potatoes. 
It  can  be  secured  as  tablets.  Agar-agar  may  be  employed  alone.  The 
writer  believes  regulin  to  be  of  considerable  value.  It  can  be  given  t.i.d. 
if  required.  One  to  three  or  four  tablespoons  of  wheat  bran  in  a  glass  of 
cold  water  once  or  twice  after  meals  is  at  times  of  service. 

Syrup  of  tamarinds,  i  dram  (4.0),  or  a  sauce  of  tamarinds;  syrup  of 
figs,  I  to  2  drams  (4.0-8.0);  compound  licorice  powder,  i  to  4  drams 
(4.0-16.0).  This  last  gripes  some  patients.  Olive  oil  by  mouth,  i  to  2 
ounces  (30.0-60.0),  several  times  a  day  is  valuable. 

Aloes  does  not  lose  its  effect  even  when  employed  for  a  long  time,  and 
painless  defecation  results.  It  may  be  used  alone  or  in  combination.  If 
hemorrhoids  are  present  I  do  not  advise  it. 

Rhubarb  is  an  excellent  drug.  Pilula  aloes,  dose,  i  to  2  pills  at  night. 
Tincture  rhei  aromatici,  ^  to  i  dram  (2.0-4.0).  Tincture  rhei,  i  to  2 
drams  (4.0-8.0).     The  following  are  of  value: 


I^.  Tinct.  nucis  vomicae 3iss         6 

Fl.  ext.  cascara gss        16 

Pulv.  ipecac gr.  iv 

Pulv.  rhei gr.  xv 

Sod.  bicarb 5  iss         6 

Aq.  menth.  piperit q.  s.  5iv      125 

Sig. — Shake.     One  or  two  teaspoonfuls  (4.0-8.0)  three  times  a  day  in  water 
after  meals  as  a  mild  laxative. 


26 


— M. 


I^.  Pulv.  rhei 

Magnes.  usta  \ aa   3iv  (16.0). —  M. 

Sod.  bicarb.    J 
Sig. — One-half  teaspoonful  (2.0)  three  times  a  day  after  meals. 

I^.  Pulv.  aloes gr.  xx       1I3 

Ext.  balladonna      1         ■  ..  1        », 

1^  .         .  .      f aa  gr.  V  3. — M. 

Ext.  nucis  vomicae  J  °  '*' 

Ft.  pil.  No.  XX. 

Sig. — One  to  two  pills  at  night. 

Podophyllin  combinations  are  quite  useful. 

^.  Podophyllin  1 

Ext.  physostigmatis  | aa  gr.  v  I3. — M. 

Ext.  nucis  vomicae    J 
Ft.  pil.  No.  xxx. 
Sig. — One  pill  at  night  and  in  the  morning  if  required. 

R.  Pil.  colocynthi  comp.  |  __         .  ,      ,  \ 

Pil.rheicomp.  f aa  gr.  j  (0.065). 

Ext.  hyoscyam gr.  ss  (0.032). — M. 

One  pill. 
Sig. — One  pill  before  dinner. 

I>.  Aloin gr.  H  (0.013) 

Strychnin  sulph gr.  3^o  (0.00108) 

Ext.  belladonna , gr-  H  (0.008) 

Pulv.  ipecac gr.  ^g  (0.004). — M. 

One  pill. 
Sig. — One  to  two  pills  at  bedtime. 


CONSTIPATION    AND    DIARRHEA  623 

I^.  Resinae  podophyllin gr-  H  (o.oii) 

Pil.  rhei  comp gr.  iiss  (0.162) 

Ext.  hyoscyam gr.  ^  (0.032). — M. 

One  pill. 
Sig. — One  to  two  pills  at  night. 

I^.  Ext.  colocynth  comp gr.  j  (0.065) 

Ext.  jalap gi-  H  (0.032) 

Resin  podophyllin gr.  K  (o.oi6) 

Leptandra gr.  K  (0.32) 

Ext.  hyoscyami  | S,2  gr.  J^  (0.016) 

Ext.  taraxaci       j 

01.  menth.  pepmt q.  s. — M. 

One  pill. 
Sig. — One  to  two  pills  at  bedtime. 

I^.  Aloes  ] 

Resin  of  jalap  I  .,         iy 

Resm  of  scammony  "       *" 

Turpeth  root  J 

Extract  of  belladonna     1  j. 

Extract  of  hyoscyamus  J  g-/* 

Almond  soap q.  s. — M. 

Ft.  pil.  No.  i. 
Sig. — One  to  two  pills  on  retiring. 

An  excellent  combination  of  saline  laxatives  is — 

I^.  Sodium  sulphate 3iij 

Magnesium  sulphate 3  j- — M. 

Sig. — Dissolve  in  a  half  glass  of  lukewarm  water,  add  a  quarter  of  a  glass 
of  seltzer  water,  and  drink  at  once. 

Compound  jalap  powder,  30  grains  (2.0),  with  calomel,  5  grains  (0.6), 
is  a  good  combination. 

Jalap  and  colocynth  belong  to  the  stronger  remedies,  and  I  only  em- 
ploy them  temporarily  to  empty  the  bowels.  The  same  is  true  of  castor 
oil  and  calomel. 

Hunyadi,  Friederickshall,  the  Homburg  Waters,  Carlsbad  salts,  Pluto, 
Apenta,  Rubinat,  Congress,  etc.,  may  be  necessary  for  a  brief  period,  but 
should  not  be  used  for  any  length  of  time.  In  anemic  patients  with 
constipation  the  following  pills  are  of  service: 

I^.  Pill  (Blaud's  iron) gr.  v.  (0.324) 

Aloin .  gr.  J^^o  (0.032). — M. 

One  pill. 
Sig. — One  to  two  pills  three  times  a  day  after  meals. 
or 

I^.  Blaud's  iron  pill gr.  x  (0.6) 

Pulv.  capsici- gr.  K  (0.016) 

Aloini.  ] 

Strychnin  sulph.  [ aa  gr.  J^^o  (0.0022). — M. 

Acid,  arseniosi     j 
One  pill. 
Sig. — One  pill  three  times  a  day  after  meals. 

Fecal  Colic,  Fecal  Tumor. — It  is  an  error  to  at  once  administer  large 
doses  of  cathartics,  and  in  some  cases  positive  harm  may  result.  The 
rectum  should  first  be  examined,  and  all  material  found  therein  removed 


624  DISEASES   OF   THE    STOMACH    AND   INTESTINES 

by  the  finger  and  then  by  enemata.  High  injections  of  soapsuds  and 
water,  in  all,  1500  c.c,  containing  olive  oil  8  ounces  to  i  pint  (250-500 
ex.),  should  be  given,  in  some  cases  in  the  knee-chest  posture,  in  order 
to  soften  and  remove  accumulation.  Frequent  injections  and  irrigations 
should  be  given  to  start  movement  for  the  first  twenty-four  to  forty-eight 
hours.  Ox-gall,  i  to  3  drams  (4.0-12.0),  with  glycerin,  2  to  4  ounces 
(60.0-125.0),  added  to  the  enema,  are  of  value. 

Olive  oil,  2  to  6  ounces  (60.0-200  c.c),  can  be  given  by  mouth,  if  neces- 
sary, t.i.d.  to  soften  the  dejecta.  Later,  castor  oil,  laxol  (a  tasteless 
castor  oil),  calomel,  or  compound  jalap  by  mouth,  and  saline  cathartics,  or 
eserin  gr.  Hoo-^o- 

Frequent  irrigations,  in  some  cases  with  electricity,  can  be  added  to 
the  treatment.  Large  doses  of  tincture  of  belladonna  and  strychnin  may 
later  be  of  service.  In  some  cases  it  takes  several  weeks  for  an  old 
accumulation  to  be  completely  removed.  With  marked  impaction  in- 
jection of  olive  oil  i  pint,  or  Russian  oiP  through  the  duodenal  tube  may 
be  of  value.     Vomiting  is  then  avoided  and  large  amounts  can  be  given. 

Spasm  of  the  Sphincter. — This  should  always  be  examined  for,  especially 
in  cases  of  spastic  constipation.  Gradual  dilatation,  or,  preferably,  rapid 
dilatation  under  an  anesthetic,  are  curative.  Local  disease  should  be 
treated. 

DIARRHEA 

Clinically,  diarrhea  may  be  defined  as  abnormal  rapidity  of  intestinal 
peristalsis,  accompanied  by  frequent  evacuations  of ,  the  bowel  contents, 
which  are  too  liquid,  or  are  watery  in  character. 

Some  patients  normally  pass  solid  dejecta  several  times  a  day,  but 
this  is  not  diarrhea;  yet  a  single  solid  movement  may  possess  pathologic 
significance. 

Diarrheal  stools  are  caused  by  the  excess  of  water  in  the  feces,  and 
may  be  due  to  the  liquid  contents  of  the  small  intestine  being  so  rapidly 
hurried  into  the  colon  that  little  absorption  is  able  to  occur  in  the  small 
intestine.  Free  transudation  of  water  from  the  blood-vessels  or  the  glands 
may  be  a  factor. 

Rapid  peristalsis  in  both  the  small  and  large  intestines,  or  in  the  latter 
alone,  is  another  cause. 

At  times  increased  peristalsis  is  the  only  factor,  and  there  are  no  chemic 
or  physical  changes  in  the  bowel  contents  and  no  structural  changes  in 
the  wall  of  the  gut.  Increased  peristalsis  usually  involves  the  large 
intestine  as  well  as  the  small. 

Pathologic  increase  of  intestinal  peristalsis  may  be  produced  in  numer- 
ous ways.  In  the  majority  of  cases  it  is  caused  by  intestinal  diseases  in 
which  anatomic  changes  are  present,  as  in  intestinal  catarrh,  ulcers, 
typhoid,  etc.  It  may  be  present  without  any  apparent  anatomic  lesions, 
as  a  result  of  irritants  in  the  contents  of  the  bowel;  or  when  the  contents 
are  normal,  but  the  irritability  of  the  nerves  of  the  intestinal  wall  is  in- 
creased; or  when  the  muscular  coats  of  the  intestines  are  stimulated  by 
an  irritant  circulating  in  the  blood,  or  affecting  the  central  nervous  system. 

'Russian  oil,  or  American  mineral  oil,  5i-3iii,  can  be  given  through  the  duodenal 
tube,  as  noted  above. 


CONSTIPATION    AND    DIARRHEA  625 

Frequently  there  are  several  factors.  The  appearance  of  the  evacua- 
tion, both  macroscopic  and  microscopic,  in  diarrhea  vary  according  to  the 
etiology  of  the  disease  and  the  anatomic  changes  in  the  gut,  when  such  are 
present. 

In  every  diarrhea  it  is  important  to  know  whether  it  is  produced  by 
abnormal  transudation  or  exudation,  with  increased  peristalsis  of  the  large 
intestine;  or  whether,  in  addition,  the  peristalsis  of  the  small  intestine  is 
increased.  In  the  last  event  large  quantities  of  unchanged  digestive  fluids 
and  undigested  food  remnants  are  evacuated,  and  nutrition  is  markedly 
impaired.  Bile-pigment  reaction  in  the  feces  shows  involvement  of  the 
small  intestine. 

We  may  classify  two  forms  of  diarrhea:  First,  with  intestinal  lesions; 
second,  diarrhea  without  lesions.  The  first  group  is  described  in  the 
appropriate  sections.  The  second  group,  with  no  intestinal  lesions,  is 
classified  as  follows: 

1.  Diarrhea  due  to  irritation  from  the  bowel  contents.  Diarrhea 
dyspeptica.  Diarrhea  gastrica,  Diarrhea  stercoralis,  and  Diarrhea  entozoica 
are  subdivisions. 

2.  Diarrhea  due  to  irritants  transmitted  in  the  blood,  such  as  the 
uremic  type. 

3.  Diarrhea  nervosa  (nervous  diarrhea),  due  to  irritation  of  the 
nervous  system. 

4.  Diarrhea  Cathartica. — This  type  belongs  in  a  class  by  itself.  It  is 
thus  referred  to  by  Nothnagel,  and  merely  mentioned  in  passing.  Colo- 
cynth  and  aloin  in  excess  may  also  produce  the  condition.  The  majority 
of  purgatives  stimulate  the  peristaltic  action  of  the  entire  intestinal  tract. 
The  peristaltic  action  of  the  large  intestine  is  chiefly  affected,  as  by  the 
aromatic  laxative  drugs.  The  movements  in  this  case  are  thin  and  liquid, 
since  increased  peristalsis  interferes  with  the  absorption  of  the  ingesta 
and  intestinal  secretions. 

With  the  alkaline  laxative  salts  the  action  is  not  only  to  increase  peri- 
stalsis, but  they  withdraw  the  water  from  the  blood  and  stimulate  the 
intestinal  secretions.  The  prolonged  use  of  drastic  purgatives  or  excess- 
ively large  doses  produce  an  acute  catarrh  of  the  intestines. 

Diarrhea  Due  to  Irritation  of  the  Bowel  Contents 

Diarrhea  Dyspeptica. — Certain  articles  of  diet  may  produce  diarrheal 
evacuations,  such  as  fresh  fruit,  cucumbers,  pickles,  cabbage,  turnips, 
beets,  etc.  Patients  vary  as  to  susceptibility.  Milk  produces  diarrhea 
in  some,  while  others  it  constipates.  Excess  of  food  or  too  great  ingestion 
of  water  or  beer  with  the  food  may  prevent  gastric  digestion.  The 
ingesta  entering  the  intestines  unchanged  may  cause  diarrhea. 

Intestinal  fermentation  or  putrefaction,  spoiled  food,  and  auto-in- 
loxication  may  produce  diarrhea.  With  the  last  the  diarrhea  is  due  to 
more  than  the  mere  local  irritation. 

In  neglected  or  severe  cases  of  pure  dyspeptic  diarrhea,  long-continued 
irritation  may  give  rise  to  true  catarrh. 

Diarrhea  Gastrica. — Einhorn  and  Oppler  first  called  attention  to 
diarrhea  resulting  from  disturbances  of  the  stomach  functions. 
40 


626  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Hypochlorhydria  and  achylia  gastrica  are  the  most  frequent  causes 
of  this  type  of  diarrhea;  more  rarely  hyperchlorhydria  or  motor  insuf- 
ficiency. With  hypochlorhydria  or  achylia,  diarrhea  with  intestinal 
symptoms,  such  as  flatulence,  borborygmi,  and  colicky  pains,  may  pre- 
dominate.    The  stools  are  often  quite  undigested. 

These  cases,  if  prolonged,  may  develop  intestinal  catarrh. 

Diarrhea  Stercoralis. — Diarrhea  with  constipation.  If  constipation 
occurs  in  a  person  whose  bowels  usually  are  regular,  diarrhea  may  follow 
the  attack  of  constipation.  The  diarrhea  is  accompanied  by  colicky  pains, 
bloating,  and  by  the  development  of  more  or  less  offensive  gases,  such  as 
sulphuretted  hydrogen,  etc. 

It  is  believed  that  the  diarrhea  is  caused  by  the  development  of  these 
gases  in  the  intestinal  contents,  as  a  result  of  stagnation  of  the  fecal  matter. 
Hardened  fecal  matter  may  irritate  the  mucosa  and  produce  secretion 
and  peristalsis.  With  stercoral  diarrhea,  the  passages  are  at  first  formed, 
then  mushy,  and  finally  liquid.     Scybalae  may  be  found  in  the  dejecta. 

The  passage  of  flatus  affords  temporary  relief.  Thorough  evacuation 
of  the  bowels  relieves  all  the  symptoms.  Neglected  cases  may  cause 
intestinal  catarrh. 

Diarrhea  Entozoica. — Intestinal  parasites,  the  tapeworm,  for  ex- 
ample, may  in  some  cases  cause  persistent  diarrhea.  Like  other  types  of 
diarrhea,  there  are  probably  at  first  no  changes  in  the  mucosa,  but  long- 
continued  irritation  will  produce  catarrh. 

Diarrhea  Due  to  Irritants  Transmitted  in  the  Blood 

Diarrhea  due  to  the  hypodermic  injection  of  certain  drugs  belongs  to 
this  class.  The  diarrheas  of  septicemia,  nephritis,  diabetes,  cholera, 
malaria,  etc.,  are  explainable  by  this  theory. 

Diarrhea  Nervosa  (Nervous  Diarrhea) 

This  type  depends  on  nervous  disturbances,  without  any  morbid 
changes  in  the  walls  of  the  intestines.  Trousseau  first  described  nervous 
diarrhea.     No  impairment  of  digestive  functions  is  present. 

It  originates  either  from  excessive  stimulation  of  the  nerves  governing 
peristalsis  (the  motor  function)  or  from  the  transudation  of  serous  material 
into  the  intestinal  canal  (secretory  function),  produced  by  nervous 
influences.     In  some  cases  probably  both  factors  are  concerned. 

The  stimulus  may  arise  from  the  nerve-centers  and  be  transmitted 
through  the  fibers  of  the  vagus,  sympathetic,  or  splanchnic  nerves  to  the 
intestinal  ganglia. 

As  an  example  of  nervous  diarrhea,  numerous  watery  evacuations  may 
occur  as  the  result  of  some  emotion,  such  as  fright  or  shock,  in  which  cases 
the  stimulus  arises  in  the  brain  centers.  These  are  more  especially  acute 
transitory  attacks. 

Nothnagel  and  Peyer^  report  instances  of  chronic  nervous  diarrhea: 
thus,  some  persons  will  be  attacked  with  gurgling,  abdominal  pain,  tenes- 

»  Wiener  Klinik,  1893,  Heft  i. 


CONSTIPATION    AND    DIARRHEA  627 

mus,  and  diarrhea  as  soon  as  they  find  they  can  secure  no  access  to  a 
water-closet;  while  with  others  the  sight  of  the  toilet  produces  diarrhea. 
Some  patients  may  have  attacks  at  definite  hours,  without  any  relation 
to  surrounding  conditions. 

In  others,  nervous  symptoms  precede  the  diarrhea,  such  as  vertigo, 
stupor,  giddiness,  congestion  of  the  head,  reddening  of  the  face,  hot  flushes 
over  the  body,  fear,  oppression,  palpitation,  rapid  breathing,  etc.  These 
symptoms  often  disappear  after  a  few  diarrheal  movements. 

The  number  of  stools  varies;  these  may  be  from  two  to  four,  or  even 
to  fifteen,  consisting  of  thin  liquid  contents,  with  mucus  rarely  present. 
At  times  the  first  movement  is  solid,  the  next  mushy,  and  the  subsequent 
movements  liquid. 

Occasionally  peristaltic  unrest,  borborygmi,  and  severe  tenesmus  may 
accompany  the  movements. 

This  form  of  diarrhea  is  found  as  a  symptom  in  hysteria  or  neurasthenia, 
in  the  nervous  and  debilitated,  and  even  in  healthy  persons  after  a  nervous 
shock. 

With  Graves'  disease  and  migraine  this  type  may  occasionally  occur. 

Charcot^  describes  attacks  with  tabes  (intestinal  crisis).  Peyer  speaks 
of  a  reflex  form  of  nervous  diarrhea  found  in  consequence  of  abnormal 
processes  in  the  genito-urinary  tract;  for  example,  in  uterine  catarrh, 
emissions,  spermatorrhea,  and  sexual  excess. 

Fischl  cites  a  case  of  diarrhea  which  persisted  for  several  years  and 
resisted  all  treatment.     Replacement  of  a  reflexed  uterus  cured  the  case. 

Vicarious  diarrhea  in  pregnant  women  of  the  neuropathic  type  has 
been  described  by  Condio.     The  diarrhea  takes  the  place  of  vomiting. 

Nervous  diarrhea  has  also  been  attributed  to  excessive  smoking. 

Diarrhea  from  Exposure  to  Cold  and  Wet 

This  occurs  after  a  sudden  or  severe  chill  from  exposure  to  cold, 
or  wetting  of  the  surface  of  the  body,  especially  the  feet  or  abdomen. 
Probably  it  is  due  to  reflex  irritation,  transmitted  from  the  cutaneous 
nerves. 

Accelerated  peristalsis  of  the  intestines  occurs,  whether  due  to  reflex 
stimulation  or  secondary  to  hyperemia,  it  is  uncertain.  This  type  of 
diarrhea  is  usually  transitory.  At  times  it  may  assume  the  character  of 
true  intestinal  catarrh. 

Treatment  of  Diarrhea 

The  method  of  treatment  depends  on  the  cause.  In  the  cases  with 
anatomic  lesions  in  the  intestines,  regulation  of  the  diet  and  medication 
appropriate  to  each  special  type  should  be  carried  out.  These  methods 
are  described  under  their  special  sections,  such  as  under  Intestinal  Catarrh, 
Dysentery,  etc. 

With  diarrhea  due  to  a  laxative,  heat  to  the  abdomen  and  opium  are 
indicated.  Pilulae  opii,  i  grain  (0.065),  three  or  four  times  a  day,  or  one 
of  the  other  opium  preparations,  or, 

■  Prager  med.  Wochenschr.,  1891. 


628  DISEASES    OF    THE    STOMACH   AND   INTESTINES 


I^.  Tinct.  opii Siiss 

Bismuth  subnit 3iij 

Mist,  cretae q.  s.   5  iv 

Sig. — Shake.     Two  teaspoonfuls  (8.0)  four  times  a  day. 


12 

125.— M. 


With  dyspeptic  and  stercoral  diarrheas  thorough  removal  of  the  sources 
of  irritation  are  indicated,  such  as  the  use  of  calomel  or  blue  mass,  5  grains 
(0.3),  castor  oil  or  laxol,  i}^^  ounces  (45.0),  or  a  saline  cathartic,  such  as 
magnesium  sulphate,  ^  to  i  ounce  (15-30  grams),  or  Sprudel  salts,  apenta, 
etc.     Intestinal  irrigation  is  indicated  in  these  types. 

For  intestinal  parasites  an  appropriate  remedy  and  a  cathartic  should 
be  administered. 

For  Diarrhea  Gastrica. — Treatment  should  be  given  for  the  existing 
condition  in  the  stomach;  for  hypochlorhydria,  stomachics,  dilute 
hydrochloric  acid,  intragastric  faradization,  etc. 

For  achylia  gastrica,  chiefly  vegetable  food,  finely  divided,  and  the 
methods  employed  for  this  condition. 

•For  hyperchlorhydria,  a  rare  cause,  diet  and  the  alkalis,  etc.,  are 
indicated. 

For  Diarrhea  Due  to  Irritants  Transmitted  in  the  Blood.-^The  cause 
should  receive  treatment,  thus,  nephritis,  malaria,  etc.  The  general 
condition  should  be  improved. 

Heat  locally  to  the  abdomen,  liquid  diet,  rest  in  bed,  the  bismuth  and 
astringent  preparations,  sUch  as  bismuth  subnitrate,  30  grains  (3.0)  t.i.d., 
bismuth  salicylate,  10  grains  (0.6)  t.i.d.,  or  bismuth  subgallate,  10  grains 
(0.6)  four  times  a  day;  or  tannalbin,  tannigen,  or  tannopin,  or  tanocol, 
10  grains  (0.6)  each,  three  or  four  times  a  day. 

Opium  preparations  may  be  required,  but  they  should  be  used  with 
caution. 

Nervous  Diarrhea. — If  this  depends  on  reflex  action,  such  as  from 
uterine  disturbance,  etc.,  the  primary  affection  must  be  treated. 

In  other  cases,  the  general  -condition  of  the  patient  must  be  built  up. 
Neurasthenic  and  hysteric  conditions  must  receive  special  treatment. 
Constipating  food  may  be  administered. 

Iron  preparations,  such  as  iron  tropon,  i  to  2  drams  (4.0-8.0),  t.i.d.;  or 
Fowler's  solution  of  arsenic,  5  minims  (0.296  c.c),  or  smaller  doses  t.i.d.; 
or  sodium  arsenate,  }4o  to  ^5  grain  (0.0013-0.0026),  are  of  value  as  tonics. 

I^.  Blaud's  iron  pill gr.  v  (0.6) 

Sodium  arsenate gr.  )^o  (0.0013). — M. 

One  pill.     Make  30  such  pills  soft  with  honey  and  silver  coat. 
Sig. — One  three  times  a  day  after  meals. 

The  bromids  of  sodium,  ammonium,  or  potassium,  or  Dromid  of 
strontium,  given  for  a  few  weeks,  15  to  30  grains  (1.0-2.0)  t.i.d.,  lessen 
irritability.     The  glycerophosphates  are  useful. 

Bismuth  subnitrate  or  salicylate,  in  dosage  already  given,  silver  nitrate, 
yi  to  \i  grain  (0.008-0.016)  t.i.d.,  and  the  astringents  noted  above  are 
useful.     Heat  should  be  applied. 

Opium  and  its  derivatives  are  generally  recommended  for  this,  as  well 
as  other  types  of  diarrhea,  and  are  preferable  to  morphin. 

The  general  tendency  to  at  once  prescribe  opiates  in  all  diarrheas,  is 


CONSTIPATION    AND    DIARRHEA  629 

to  be  deplored,  especially  in  the  nervous  type,  as  the  habit  is  readily 
gained.  If  other  remedies  fail,  they  may  be  used  with  caution.  The 
following  (Wm.  H.  Thomson)  is  a  useful  combination  for  such  purposes. 
The  dosage  is  small : 

R.  Pulv.  opii       1  ,_  ,     ^ 

^    „.,  .^    ^     / aa  gr.  V  (0.3) 

Silver  nitrate  J  b        v    0/ 

Resin  of  turpentine 3ij  (8.0) 

Liquor  potass 3j  v4-o) 

Pulv.  licorice q.     s.     to    make    pills    soft. — M. 

Divide  in  pil.  No.  Ix. 

Sig. — ^Two  or  three  pills  three  times  a  day. 

1^.  Tinct.  opii  camphor  \  aa  ^ss  fi6  o) 

Bismuth  subnit.         / ^  ^^^  ^^^'°' 

Mist,  cretae q.  s.  %vv  (125  c.c). — M. 

Shake. 
Sig. — Two  teaspoonfuls  in  water  every  two  or  three  hours. 

I^.  Tinct.  opii 5>ij  (12.0) 

Tinct.  catechu  comp .    5ss  (16.0) 

Aq.  destil q.   s.   ad.     5iv  (125  c.c). — M. 

Shake. 
Sig. — Two  teaspoonfuls  in  water  every  three  hours. 

Opium  pills  or  other  combinations  can  be  employed. 

For  nervous  diarrhea  the  intestines  should  be  trained  in  the  normal 
direction.  Suggestion  by  the  physician  is  of  value.  The  patient  should 
be  instructed  that  after  his  morning  evacuation  he  should  refrain  from 
other  movements  except  when  absolutely  necessary.  Often  he  can  thus 
control  the  desire. 


CHAPTER  XXIV 

CHRONIC  mXESTINAL  STASIS 

(Lane's  Kinks.     Dilatation  of  the  Duodenum.     Jackson's  Membrane. 

Movable  Cecum.     Incompetent  Ileocecal  Valve.     Angulations 

and  Adhesions.     Dilated  Sigmoid) 

Chronic  intestinal  stasis  is  our  old  friend  "chronic  constipation"  with 
a  new  name,  of  which  the  causes  are  manifold.  Lane  and  his  followers 
consider  mechanical  conditions,  special  kinks  (angulations)  as  the  chief 
factors  in  the  production  of  intestinal  stasis  and  that  certain  evolutionary 
membranes  developing  on  the  peritoneum  reflected  from  the  large  and 
partictdarly  from  the  small  intestines,  have  a  decided  influence  in  the  pro- 
duction of  kinks  and  resulting  stasis. 

It  is  interesting  to  note  that  Glenard  many  years  ago  called  to  our 
attention  that  kinks  or  angulations,  of  the  transverse  colon  particularly, 
result  from  enteroptosis,  and  interference  with  passage  of  the  intestinal 
contents  ensues.  He  furthermore  specifically  refers  to  similar  angulations 
which  may  occur  with  splanchnoptosis,  at  the  gastroduodenal,  dtwdeno- 
jejunal  and  sigmoido-rectal  curves — all  interfering  with  the  passage  of  con- 
tents by  enterostenosis  and  he  was  the  first  to  realize  that  many  cases  of 
so-called  nervous  dyspepsia  were  dependent  on  these  abnormalities. 
These  features  are  referred  to  under  "  Glenard's  Disease."  Lane  describes 
numerous  kinks,  some  of  which  correspond  to  the  above.  He  defines^ 
chronic  intestinal  stasis  as  "a  delay  in  the  passage  of  the  contents  of  the 
intestinal  canal,  of  sufficient  length  as  to  result  in  the  production  in  the 
small  intestine  especially,  of  an  excess  of  toxic  material,  and  in  the  absorp- 
tion into  the  circulation  of  a  greater  quantity  of  poisonous  products  than 
the  organs  which  convert  and  excrete  them,  are  able  to  deal  with.  In 
consequence  there  exist  in  the  circulation  materials  which  produce  degen- 
erative changes  in  every  single  tissue  of  the  body  and  lower  its  resisting 
power  to  invasion  by  deleterious  organisms."  Lane  refers  later  to  the 
symptoms  occurring  from  the  "auto-intoxication"  of  chronic  intestinal 
stasis.  This  term,  "auto-intoxication,"  is  a  misnomer,  as  direct  bacterial 
infection,  subinfection,  or  chronic  intestinal  putrefaction  might  respect- 
ively be  responsible  for  the  various  symptoms.  In  the  above  definition 
of  Lane,  particular  stress  is  placed  on  the  stasis  in  the  small  intestines  and 
resulting  absorption  of  toxic  material. 

The  contents  of  the  small  intestines  are  liquid  and  marked  narrowing, 
or  angulation,  is  necessary  to  interfere  with  their  passage.  Moreover  the 
motility  of  the  small  intestine  is  rapid,  which  makes  stasis  from  an  angu- 
lation still  less  easy  to  occur.  Reversely  in  the  large  intestine,  motility  is 
slow,  the  contents  are  solid,  and  stasis  from  an  angulation  or  adhesions 
easily  results.     Study  of  the  radiographs  of  Glenard's  disease  confirms 

^  Brit.  Med.  Jour.,  Nov.  i,  1913. 
630 


CHRONIC   INTESTINAL    STASIS  63 1 

this  view.  The  motility  of  the  stomach  is  often  excellent,  though  depend- 
ent somewhat  on  the  degree  of  the  descent  of  the  duodenum  and  the  type 
(shape)  of  the  stomach.  On  the  other  hand,  in  spite  of  the  marked 
enteroptosis  of  the  small  intestines,  their  motility  is  usually  found  to  be 
excellent.  Nature  is  a  wonderful  "compensator."  When  stasis  occurs, 
it  is  usually  found  in  the  large  intestine,  where  the  angulations  have  a 
marked  influence  in  retarding  the  movements.  Of  course  there  are  ex- 
ceptions and  we  know  enteroptosis  is  present  with  Lane's  kinks.  About 
one-third  of  my  gastro-intestinal  cases  have  splanchnoptosis,  yet  I  find  few 
iliac,  or  gastroduodenal,  or  duodeno-jejunal  kinks.  Many,  however, 
have  angulations  of  the  colon  and  some  of  them  adhesions,  with  stasis. 
I  advise  operation  on  rare  occasions,  as  medical  treatment  usually  results 
favorably.  Moreover,  some  individuals  normally  have  bowel  action  every 
second  or  third  day  and  yet  no  symptoms  result,  while  other  adipose  in- 
dividuals taking  no  exercise,  yet  with  daily  bowel  action  may  suffer  from 
indicanuria  with  nervous  symptoms,  resulting  from  faulty  metabolism 
and  improper  diet. 

Etiology. — ^Lane  holds  that  an  unsuitable  diet  in  infancy,  and  the 
habitual  assumption  of  the  erect  position  result  in  delay  of  fecal  material 
in  the  large  intestine.  Consequently  new  membranes,  or  folds,  or  "re- 
sistances to  downward  displacement,"  are  formed  by  the  '^  chrystallization 
of  lines  of  force  upon  the  surface  of  the  peritoneum  along  which  strain  is 
specially  exerted." 

Others  believe  these  membranes  or  folds  are  congenital  (of  fetal  devel- 
opment); or  that  they  are  more  likely  to  result  from  infection  from  bac- 
teria, or  their  toxins,  emanating  from  the  intestinal  canal. 

Lane's  kinks  and  membranes  are  as  follows:  the  "first  and  last  kink," 
the  first  to  form  and  the  lowest  in  the  bowel,  is  a  membrane  fixing  the  large 
bowel  on  the  left  side  to  the  pelvic  brim.  It  may  attach  itself  to  the  left 
ovary  rendering  it  cystic  and  producing  a  tumor.  The  stenosed  region 
in  the  intestine  may  become  the  seat  of  cancer.  Evolutionary  membranes 
are  developed  on  the  surface  of  the  peritoneum  which  is  reflected  from  the 
cecum,  ascending  and  descending  colon.  They  are  exaggerated  at  the 
splenic  and  hepatic  flexures.  Membranes  also  develop  between  the  trans- 
verse prolapsed  colon  and  the  adjacent  ascending  and  descending  colon. 
There  are  angulations  (or  kinks)  in  the  locations  described.  The  appendix 
may  be  anchored  by  an  acquired  membrane  passing  upward  and  outward 
from  the  cecum  and  thus  become  kinked  or  obstructed  and"appendicitis" 
result  from  inflammation.  Obstruction  in  any  part  of  the  intestine  may 
result  in  inflammation  or  cancer.  Kinking  of  the  sigmoid  loop  from  evolu- 
tionary bands  may  also  occur.  Accumulation  of  material  in  a  large  pro- 
lapsed cecum  may  cause  delay  in  evacuation  of  the  ileum  and  accumtda- 
tion  in  the  small  intestines. 

As  a  result  of  traction,  a  thickening  (developmental  membrane)  forms 
on  the  undersurface  of  the  mesentery  partially  obstructing  the  lumen  of 
the  ileum.  This  "ileal  kink"  upon  which  great  stress  is  placed  by  Lane, 
develops  about  2  inches  from  the  termination  of  the  ileum.  Fixation  of 
the  appendix  to  the  undersurface  of  the  iliac  mesentery  by  acquired 
adhesions  (evolutionary  according  to  Lane)  may  further  kink  or  obstruct 


632  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

the  ileum.  (See  Fig.  285.)  Accumulation  of  material  in  the  small  intes- 
tine drags  upon  the  duodeno-jejunal  junction  and  forms  a  kink  at  that 
point,  where  also  an  evolutionary  membrane  develops  (Fig.  286).  Conse- 
quently the  duodenum  becomes  elongated  and  dilated.  Spasmodic  con- 
tractions of  the  pylorus  result  in  the  endeavor  to  prevent  regurgitation 
of  duodenal  contents.  Chrystallization  of  a  membrane  occurs  at  the 
pyloric  opening  (according  to  Lane)  with  further  increase  of  gastric  dila- 
tation. Stasis  in  the  small  intestines  and  stomach  results  in  infection  by 
organisms  and  chemical  changes.  As  a  result,  we  have  engorgement  of 
the  mucosa  of  the  ascending  duodenum,  with  ulcer  and  even  perforation; 
or  similar  conditions  at  the  pylorus  or  lesser  curvature  of  the  stomach, 
with  resulting  ulceration,  perforation,  or  cancer;  pancreatic  infection  with 
ultimate  degeneration  or  even  cancer;  infection  of  the  ducts  of  the  liver 
or  gall-bladder  with  resulting  gall-stones,  cholecystitis,  or  cancer;  acute 
and  chronic  diseases  of  the  liver  and  spasm  of  the  cardiac  orifice  of  the 
esophagus. 

The  writer  by  no  means  subscribes  to  many  of  these  claims  of  Lane 
and  Gordan^  (the  latter's  radiologist).  For  example,  "a  duodenal  ulcer 
only  occurs  in  the  distended  duodenum  of  intestinal  stasis  "  (Jordan).  Under 
one  radiograph,  "There  was  malignant  disease  of  the  pancreas,  the  final 
stage  of  long-continued  chronic  pancreatitis."  An  adjacent  interstitial 
pancreatitis  occurs  with  pancreatic  cancer.  It  is  "new  pathology"  to 
consider  cancer  of  the  pancreas  a  final  stage  of  chronic  pancreatitis. 

Among  the  symptoms  of  chronic  intestinal  stasis  from  auto-intoxication 
the  following  are  described  by  Lane:  loss  of  fat,  wasting  of  the  voluntary 
and  involuntary  muscles,  subnormal  temperature,  extremities  bloodless, 
vnth  loss  of  sensation,  appearing  to  be  a  stage  of  Raynaud's  disease,  blue 
hands  and  blue  skin  ("microbic  cyanosis").  Degenerative  changes  in 
the  skin  with  alteration  in  texture  and  color  with  pigmentation  and  offen- 
sive odor  to  the  perspiration  may  occur.  The  mental  condition  may  be 
one  of  apathy,  misery  or  stupidity,  melancholia,  or  apparently  imbecility 
and  these  patients  are  liable  to  commit  suicide. 

Parenthetically,  the  author,  during  fourteen  years  service  as  gastro- 
enterologist  to  the  Manhattan  State  Hospital  for  the  Insane,  an  institution 
of  4600  beds  has  never  seen  or  heard  of  a  case  of  suicide  from  this  cause. 
Among  other  symptoms  described  are  sleeplessness,  neuralgias,  neuritis 
and  epileptiform  tic,  headache,  loss  of  control  of  the  temper  making  the 
patient  difl&cult  to  live  with  and  leading  to  misery  and  crime  (a  more 
frequent  cause  of  the  latter  than  imagined) ;  rheumatic  pains  in  the  mus- 
cles, joints  and  skin;  wasting  of  the  thyroid,  so  that  it  cannot  be  felt  and 
elevation  or  lowering  of  the  blood-pressure.  The  breasts  show  definite 
degenerative  changes  which  are  most  marked  in  the  upper  and  outer  zone, 
especially  in  the  left  breast,  from  which  cancer  readily  develops.  The 
several  organs  prolapse  and  alter  in  shape  because  of  loss  of  fat  and  wasting 
muscle  fiber,  for  example  acquired  mobility  of  the  kidneys  and  uterine 
prolapse.  Incidentally  Lane  describes  downward  displacement  (enterop- 
tosis)  and  his  medical  treatment  is  that  of  this  condition.  Shortness  of 
breath,  produced  by  asthmatic  attacks  or  gastro-intestinal  distention, 
1  International   Journal   of   Surgery,   .\pril,    1914. 


CHRONIC   INTESTINAL   STASIS  633. 

occurs.  Among  the  cardiac  changes  are  dilatation  of  the  left  heart  and 
aorta  with  degeneration  of  its  coats  and  atheromatous  changes  in  the  small 
vessels  as  well.  Degenerative  and  inflammatory  changes  occur  in  the 
kidneys.  The  hair  loses  its  color  and  tends  to  fall  out,  more  so  in  the  case 
of  dark  hair  while  "red  heads"  suffer  little.  Hair  grows  excessively 
where  it  is  usually  absent  or  inconspicuous,  such  as  about  the  nipple,  and 
along  the  middle  of  the  back,^  on  the  cheeks,  chin,  upper  lip  a.nd  forearms. 
The  author  presumes  this  last  statement  refers  to  women  chiefly,  and  that 
some  of  "our  freaks"  would  be  explained  on  the  "kink  theory."  Infection 
of  the  pancreas  may  occur  with  resulting  chronic  induration,  inflammation 
and  cancer,  or  diabetes.  The  liver  and  gall-bladder  are  infected,  gall- 
stones, cholecystitis  and  cancer  may  result  or  acute  or  chronic  liver  dis- 
ease. Diseases  of  the  eye  which  are  degenerative  in  origin  may  be  pro- 
duced. Lane  refers  to  indirect  changes,  or  those  that  result  from  the 
lowered  resisting  power  of  the  tissues  to  the  exclusion  of  organisms  produced 
by  auto-intoxication.  How  long  since,  has  auto-intoxication  produced 
organisms?     (Author.) 

Among  these  changes  are  pyorrhea  alveolaris,  tuberculous  infection 
when  not  produced  by  direct  inoculation,  rheumatoid  arthritis  and  infec- 
tion of  the  genito-urinary  tract  either  directly  or  indirectly  through  the 
blood-stream  by  organisms  other  than  tubercle  producing  nephritis, 
cystitis,  pyelitis  endometritis,  salpingitis,  etc.  This  last  type  seems  to 
the  writer  suspiciously  like  colon  bacillus  infection. 

In  addition,  there  may  be  changes  in  the  thyroid  gland,  such  as  ade- 
noma, general  enlargement  or  Graves'  disease;  Still's  disease  (polyarthritis 
affecting  children  and  marked  by  enlargement  of  the  lymph-nodes) ;  pus- 
tular infections  of  the  skin;  varieties  of  mucous  and  ulcerative  colitis  pro- 
duced by  infection  of  organisms,  and  ulcerative  endocarditis.  The 
dentists  treat  many  cases  of  pyorrhea  and  when  related  to  gastro-intes- 
tinal  disturbances  it  is  usually  considered  primary.  Pus-producing  organ- 
isms occur  with  it  and  recently  some  cases  of  amebic  infection  have  been 
reported.  We  have,  of  course,  colon  bacillus  infection  with  endocarditis, 
but  there  are  other  causes. 

Treatment. — Lane  advocates  liquid  paraffin  before  meals  and  a  leather 
spring  abdominal  support  which  holds  up  the  prolapsed  viscera.  He 
avoids  butchers'  meat.  In  other  words,  his  medical  treatment  is  that  of 
enteroptosis  to  which  I  refer  my  readers,  with  appropriate  diet  and  treat- 
ment of  chronic  intestinal  putrefaction.  Paraffin  or  Russian  mineral  oil 
may  not  prove  sufficient  to  improve  the  constipation  in  which  event 
further  medical  treatment  must  be  instituted.  If  the  medical  measures 
fail  to  relieve,  the  iliac  kink  being  demonstrated  by  the  .r-ray,  removal  of 
an  appendix  anchored  to  the  mesentery  of  the  ileum  may  relieve  the  kink, 
or  if  a  membrane  is  the  cause,  dividing  this  band  may  relieve  the  condition. 
The  author  is  prepared  to  agree  with  Lane  as  far  as  appendectomy,  or 
section  of  the  band  is  concerned,  though  in  the  latter  event  adhesions  may 
reform  necessitating  a  second  operation.  Lane  holds  that  if  the  band  is 
not  limited  in  breadth  and  not  very  tense,  that  it  is  better  to  short-circuit 
by  dividing  the  ileum  and  attaching  it  to  the  pelvic  colon,  but  removes 
'  Brit.  Med.  Jour.,  Nov.  1,  1913. 


(534  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

the  large  bowel  in  addition  if  it  is  loose  and  pendulous.  At  the  Guy's 
Hospital,  London,  from  May,  1909  to  October,  1913,  there  were  performed 
54  short-circuits  and  52  removals  of  the  colon  for  various  conditions,  such 
as  intestinal  stasis,  rheumatoid  arthritis,  tuberculous  joints,  Graves'  dis- 
ease, cancer,  trigeminal  neuralgia,  etc.,  with  a  mortality  of  7.5  per  cent. 
It  would  seem  to  the  writer  that  the  physical  condition  of  several  of  these 
patients  would  contraindicate  such  radical  operations,  though  even,  so  the 
death  rate  was  low  with  a  skilled  operator  such  as  Lane.  Lane^  reports, 
for  example,  17  cases,  in  about  15  of  which  cure  is  stated  to  have  been 
secured,  with  marked  improvement  in  two.  Twenty-six  various  opera- 
tions were  performed  on  these  17  patients.  Wm.  Seaman  Bainbridge^ 
reports  favorably  on  Lane's  operations. 

Morison^  has  employed  chiefly  ileo-colotomy  in  most  cases,  but  also 
colectomy  particularly  in  the  treatment  of  obstinate  tuberculous  lesions 
especially  of  the  bones  and  glands  in  cases  of  evident  stasis  and  also  in 
rheumatoid  arthritis.  Out  of  18  tuberculous  cases,  five  died,  subsequently. 
Three  healed  after  operation  and  three  improved.  The  rheumatoid  arthri- 
tic cases  improved  but  later  relapsed.  Drummond^  by  his  radiographs 
showed  that  after  the  ileo-colostomy,  there  were  regurgitation  of  the  bis- 
muth into  the  short-circuited  colon,  complete  evacuation  of  the  colon  was 
delayed  and  the  last  portion  of  the  ileum  above  the  anastomosis  tends  to 
become  dilated  and  form  a  fecal  reservoir.  Wm.  J.  Mayo,  in  about  20 
cases  of  exaggerated  ceco-colic  stasis  with  nervous  symptoms  and  in  whom 
constipation  amounting  to  obstipation  was  present,  due  to  bands,  kinks  and 
adhesions,  removed  10  inches  of  the  terminal  ileum,  the  appendix,  cecum, 
ascending  colon,  hepatic  flexure  of  the  colon,  but  to  no  extent  that  part 
containing  the  omentum,  since  severe  adhesions  often  follow  removal  of 
the  latter.  Constipation  was  relieved  in  87  per  cent.  Mayo  concludes 
as  follows:  The  number  of  persons  whose  condition  in  our  opinion  would 
warrant  the  risk,  however,  is  comparatively  small,  and  I  cannot  but 
deplore  the  widespread  adoption  by  the  medical  profession  of  surgical 
measures  for  this  or  allied  conditions  which  is  in  the  experimental  stage 
with  little  evidence  to  show  that  the  supposed  cures  are  permanent." 
The  writer  feels  that  he  must  at  present  hold  conservative  views  and  does 
not  advocate  the  radical  procedures  of  Lane  except  in  rare  instances  of 
progressive  obstipation,  or  of  cancer. 

CHRONIC  DILATATION  OF  THE  DUODENUM 

In  view  of  the  importance  attributed  by  Lane  to  chronic  dilatation  of 
the  duodenum,  due  to  the  duodeno-jejunal  kink  resulting  from  stasis  of 
the  ileum,  it  seems  advisable  to  describe  this  subject  at  this  point.  I  have 
already  referred  to  the  fact  that  the  motility  of  the  duodenum  is  rapid. 
Moreover,  the  gastric  contents  macerated  and  partially  prepared  for  diges- 
tion are  expelled  intermittently  into  the  duodenum  in  small  quantities, 
so  that  considerable  angulation  or  stenosis  of  the  duodenum  must  occur 

^  Brit.  Med.  Jour.,  Nov.  i,  1913. 

2  Med.  Rec,  Sept.  27,  1913  and  Woman's  Med.  Jour.,  Jan.,  1914. 

'  International  Journal  of  Surgery,  April,  1914. 

*  International  Journal  of  Surgery,  April,  1914. 


CHRONIC   INTESTINAL   STASIS  635 

before  symptoms  result.  Even  though  the  x-rays  may  actually  show  some 
dilatation,  there  may  still  be  sufficient  motility  to  empty  the  duodenum 
without  the  production  of  symptoms  that  could  be  imputed  to  the  dilata- 
tion.    This  last  is  demonstrated  among  the  classes  of  cases  described. 

First. — Chronic  duodenal  dilatation  occurs  with  some  cases  of  gas- 
troptosis,  distention  occurring  on  account  of  its  prolapse  and  the  muscular 
action  of  a  stomach  of  good  motility,  rapidly  distending  the  dependent 
duodenum  {i.e.,  gravity  plays  a  part).  There  is,  however,  sufficient 
motility  for  the  latter  to  empty  itself  without  the  production  of  symptoms 
that  could  be  imputed  to  the  dilated  duodenum.  This  condition  has  been 
noted  during  the  general  a;-ray  examination  for  splanchnoptosis.  It  is 
possible  in  extreme  cases,  to  have  nausea  and  vomiting  as  a  result  of  reten- 
tion in  the  duodenum,  though  sometimes  a  marked  water-trap,  or  fish- 
hook stomach  may  be  a  factor.  Rarely  these  patients  complain  of  pains 
simulating  ulcer.  Usually  proper  mechanical  support  to  the  abdomen, 
with  treatment  for  enteroptosis  affords  relief  even  in  the  marked  cases — 
though  temporary  rest  in  bed  occasionally  may  be  required.  Operation 
is  a  rare  necessity.  During  an  experience  of  many  years,  I  have  had 
numerous  cases  with  vomiting,  relieved  by  Rose's  belt  and  proper  treat- 
ment I  have  never  as  yet  had  to  resort  to  operation  in  this  type.  Occa- 
sionally these  patients  through  the  drag  of  the  ptosed  duodenum  causing 
torsion  of  the  duct  have  attacks  of  jaundice,  or  other  attacks  simulating 
gall-stones,  cured  by  proper  corsets  or  mechanical  support  and  treatment 
of  the  enteroptosis. 

Second. — Under  the  rc-ray  section,  I  have  referred  to  dilatation  of  the 
duodenum  from  adhesions  extending  from  the  transverse  colon  to  the 
duodenum,  with  symptoms  simulating  duodenal  ulcer.  Operations  dem- 
onstrated that  no  ulcer  was  present  and  separation  of  the  adhesions  relieved 
the  symptoms. 

Third. — I  further  reported  a  case  of  chronic  pancreatitis  with  marked 
diarrhea  and  symptoms  suggestive  of  gall-stones.  There  was  retention 
in  the  duodenum  due  to  obstruction  from  adhesions.  There  were  no 
symptoms  referable  to  the  dilated  duodenum.  Moreover,  recently  the 
writer  has  examined  a  patient  in  whom  the  a;-rays  showed  dilatation  of  the 
duodenum  with  marked  deformity — resulting  from  adhesions  following 
cholecystectomy — which  extended  also  to  the  transverse  colon.  Dragging 
pains  and  local  tenderness  were  marked — so  much  so  that  the  patient 
was  continuously  endeavoring  to  use  opiates  in  order  to  obtain  relief. 

Fourth. — Dilatation  of  the  duodenum  with  symptoms  simulating  duo- 
denal ulcer  or  gall-bladder  disease  have  been  reported  by  Harris  as  due  to 
abnormal  folds  of  the  anterior  mesogastrium  (embryonic).  No  ulcers 
were  found  on  operation. 

Fifth. — Duodenal  dilatation  due  to  duodeno-jejunal  angulation,  pro- 
duced by  the  drag  weight  of  the  dilated  ileum  caused  by  the  iliac  kink 
according  to  Lane,  was  described  in  the  previous  article;  duodenal  ulcer 
disease  of  the  gall-bladder,  pancreas,  etc.,  were  attributed  to  this  condition. 

Sixth. — Bloodgood  holds  that  a  prolapsed  dilated  cecum  with  a  short 
mesentery  to  the  ileum  may  produce  a  kink  and  subsequently  dilated 
duodenum. 


636  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Seventh. — In  competent  ileocecal  valve  according  to  Kellogg  and  Case 
produces  iliac  distention,  a  drag  at  the  duodeno-jejunal  junction  and 
dilated  duodenum. 

Determination  of  Chronic  Duodenal  Dilatation. — The  a;-rays  are  the 
most  accurate  method.  The  duodenum  is  seen  to  be  dilated,  or  in  milder 
cases  there  will  be  retention  of  bismuth  or  barium.  When  marked  adhe- 
sions are  present,  there  may  be  considerable  irregularity  in  the  contour. 
With  the  fluoroscope,  writhing  movements  may  be  observed,  a  hyper- 
peristalsis  of  the  duodenum  endeavoring  to  force  the  contents  past  the 
stenosis. 

Wm.  Van  Valzah  Hayes  employs  an  excellent  method  of  determining 
duodenal  dilatation  by  physical  examination. 

Hayes'  Methods  (Percussion  with  Pressure). — The  first  part  of  the 
duodenum  is  percussed  in  the  ordinary  way  as  it  lies  close  to  the  abdominal 
wall.  As  the  second  and  third  parts  lie  deep  in  the  abdomen,  deep  pres- 
sure should  be  exerted  by  the  finger  (pleximeter)  so  to  bring  it  fairly  close 
to  the  intestinal  wall.  By  this  method  of  percussion  with  pressure,  the 
distended  duodenum  can  usually  be  mapped  out. 

Corded  Colon. — Frequently  the  left  iliac  colon  is  felt  as  a  rope-like 
body  directly  beneath  the  abdominal  wall,  apparently  due  to  spasm  above 
the  sigmoid  which  occurs  with  stasis. 

Pressure  Paradox. — The  examiner  should  then  exert  pressure  upward 
and  backward  with  the  palm  of  the  hand  placed  just  below  the  umbilicus 
and  this  position  should  be  maintained  for  ten  to  twenty  seconds.  The 
gas  from  the  duodenum  can  at  times  be  felt  or  heard  passing  into  the 
jejunum  as  the  angulation  at  the  duodeno-jejunal  junction  is  thus  relieved. 
Percussion  with  pressure  is  now  repeated  over  the  duodenum  and  as  a  rule 
the  tympanites  has  disappeared.  Occasionally  deep  breathing  and  further 
gentle  pressure  may  be  necessary. 

Incompetence  of  the  iliocecal  valve  may  be  associated  with  intesti- 
nal stasis  with  Lane's  kink  (ileal).  It  is  best  demonstrated  by  the 
a-rays.  Hayes  suggests  a  useful  method  of  determining  this  condition  by 
palpation. 

Palpation  Method  of  Determining  Incompetent  Ileocecal  Valve. — If 
gas  is  not  present  in  the  cecum,  then  distend  it  artificially  with  air  or  CO2 
per  rectum.  Pressure  is  then  made  with  the  left  hand  near  the  middle  of 
the  ascending  colon.  Palpation  with  the  right  hand  shows  the  lower  por- 
tion of  the  ascending  colon  and  cecum  quite  tense.  The  tension  remains 
constant  when  gentle  pressure  is  employed,  provided  the  ileocecal  valve 
is  competent.  If  incompetent,  the  bowel  (cecum)  gradually  collapses  and 
gas  and  fluid  are  often  felt  to  pass  through  the  valve.  Percussion  now 
shows  the  absence  of  tympanitis  over  the  cecum.  At  times  the  gas  may 
be  passed  back  and  forth  between  the  ileum  and  cecum. 

Treatment. — As  enteroptosis  is  the  factor  in  most  cases,  mechanical 
support  and  its  appropriate  treatment  are  indicated.  Intestinal  putre- 
faction and  constipation  should  be  corrected  when  present.  When  ad- 
hesions are  a  factor,  pressure  should  be  relieved  by  operation.  Medical 
treatment  is  indicated  for  incompetency  of  the  ileocecal  valve  and  fre- 
quently the  treatment  of  enteroptosis  will  alleviate  Lane's  kinks,  though 


CHRONIC    INTESTINAL    STASIS 


separation  of  adhesions  (the  membrane)  may  be  necessary, 
advocate  the  more  radical  operations. 


637 

I  do  not 


JACKSON'S  MEMBRANE— PERICOLITIS 

There  has  been  considerable  confusion  in  regard  to  the  differentiation 
of  Jackson's  membrane  and  true  pericolitis.  Jackson's  membrane  belongs, 
in  the  writer's  opinion,  to  the  congenital  class  and  is  non-inflammatory. 
The  proof  of  its  developmental  origin  is  found  in  the  study  of  the  fetus 
and  new-born  infant.  Clemen^  in  36  still-born  infants  found  in  four  in- 
stances veil-like  membranes  extending  from  the  parietes  over  the  hepatic 
flexure  and  ascending  colon,  fusing  with  the  peritoneum  of  the  colon  near 
its  mesenteric  border.  He  believes  twisting  of  the  cecum  and  colon  in  their 
descent  may  be  responsible  for  drawing  attached  peritoneum  over  the  colon. 


Fig.  285. — A,  Jackson's  membrane.  B,  Multiple  Lane's  bands.  C,  Lane's  kink. 
D,  Appendix  caught  in  bands.  E,  Thickened  part  of  mesentery  forming  a  strong  band 
(W.  S.  Bainbridge). 

Jackson  holds  that  it  occurs  in  association  with  abnormal  mobility  of  the 
proximal  colon  and  is  due  to  a  failure  of  fusion  of  the  ascending  mesocolon 
with  the  posterior  parietal  peritoneum. 

Jackson's  Membrane. — Jackson  describes  this  structure  as  follows: 
"  From  a  point  just  at  the  hepatic  flexure  to  3  inches  above  the  caput  coli 
there  spreads  from  the  parietal  margin  over  the  external  lateral  margin 
to  the  internal  longitudinal  muscle  band,  a  thin  vascular  veil,  in  which 
long  straight  unbranching  blood-vessels  course,  most  of  which  are  parallel 
with  each  other  and  take  a  slightly  spiral  direction  over  the  colon  from  the 
upper  peritoneal  attachment  to  the  inner  lower  portion  of  the  gut  ending 
just  above  the  caput.  The  appendix  is  not  implicated  in  any  way. 
Coursing  with  the  blood-vessels  are  numbers  of  shining  narrow  bands  of 
connective  tissue,  which  gradually  broaden  as  they  go  and  end  in  a  slight 
*  Journal  A.  M.  A.,  July,  26,  1914. 


638 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


fan-shaped  attachment  at  various  points  on  the  anterior  and  inner  surfaces 
of  the  colon.  At  these  points  of  attachment  the  gut  is  held  in  rigid  plica- 
tion. At  the  beginning  of  the  hepatic  flexure  the  drawn  membrane  par- 
ticularly angulates  the  contained  colon." 

In  some  cases  the  folds  may  extend  further  down  the  inner  margin  of 
the  upper  part  of  the  ascending  colon  extending  to  the  descending  arm  of 
the  transverse  colon. 

Symptoms.^ — The  writer  has  had  cases  operated  on  for  other  conditions 
where  radiographs  had  been  taken  and  where  neither  they,  nor  the  symp- 
toms pointed  to  the  presence  of  Jackson's  membrane,  and  yet  when  it 
was  found  present  at  operation,  it  was  not  disturbed.  On  the  other  hand, 
one  may  have  evidences  of  stasis  in  the  cecum  and  ascending  colon  with 


Fig.  286. — A,   Kinking   at  pyloric  outlet.     B,  Duodenojejunal  kink.     C,  Dilated 
stomach.     E,  Bands  to  gall-bladder.     F,  Retractors  holding  up  liver  (W.  S.  Bainbridge). 


intestinal  disturbances,  indicanuria  and  nervous  symptoms.  Severe  con- 
stipation may  ensue  and  there  may  be  pain  over  the  region  of  the  cecum 
and  ascending  colon,  slightly  increased  on  pressure  and  intensified  four  to 
five  hours  after  meals.  From  fecal  irritation,  mucus  may  be  present  in  the 
stools. 

X-rays. — In  mild  cases  there  may  be  no  evidence,  or  merely  stasis  in 
the  cecum  and  ascending  colon  of  varying  degree.  At  times  an  angulation 
at  the  hepatic  flexure,  or  evidences  of  narrowing  from  adhesions,  or  angu- 
lation, with  frequently  displacement  of  the  cecum.  In  some  there  is  a 
"double-barrel  gun"  appearance  of  the  ascending  colon  and  descending 
arm  of  the  transverse  colon  occurring  during  the  administration  of  the 
bismuth  enema,  seen  fluoroscopically.  As  the  colon  distends  the  veil 
between  the  ascending  colon  and  arm  of  the  transverse  draws  them  to- 
gether. The  best  method  to  determine  this  condition  is  to  first  radiograph 
the  patient  standing,  after  the  barium  enema.     Then  follow  Healy's  method 

^  Journal  A.  M.  A.,  Aug.  30,  1913. 


CHRONIC   INTESTINAL   STASIS  639 

(knee-chest)  position  for  five  minutes  and  radiograph  in  the  Trendelenburg 
or  belly  Trendelenburg  (Tousey).  If  there  is  a  Jackson  membrane  the 
double-barrel  gun  appearance  persists  in  the  Trendelenburg  radiograph. 
Pericolitic  membranes  or  adhesions  likewise  are  clearly  demonstrated. 
When  there  are  no  adhesions  or  veils,  etc.,  the  transverse  colon  slips  well 
above  the  umbilicus  in  the  Trendelenburg  posture  and  swings  freely  at 
the  flexures.     Adhesions  bind  the  colon  at  some  point. 

Treatment. — Various  measures  are  advocated.  Some  immobilize  the 
cecum  when  it  is  misplaced  or  movable;  others,  the  ascending  colon. 
Division  of  the  veil  (membrane)  is  indicated  if  symptoms  occur. 

Pericolic  Membranes. — Many  of  these  membranes  resemble  that  of 
Jackson,  but  they  are  apt  to  be  thicker  in  portions  and  frequently  involve 
the  appendix.  This  type  is  believed  to  be  due  to  infection  through  the 
intestinal  wall  by  bacteria,  or  their  toxins.  The  same  type  of  membrane 
may  occur  in  the  neighborhood  of  non-perforating  gastric  and  duodenal 
ulcers.  There  is  probably  partly  a  proliferation  and  partly  a  floating  up 
of  delicate  layers  of  peritoneum  by  a  temporary  serous  exudate,  with  the 
ultimate  formation  of  lymph-spaces  and  new  blood-vessels,  with  the  forma- 
tion of  connective  tissue.     The  blood-vessels  run  in  parallel  lines. 

The  writer  has  seen  such  cases  in  association  with  chronic  appendicitis. 

The  symptoms  usually  are  more  active  than  in  many  cases  of  Jackson's 
membrane,  as  there  seems  a  greater  tendency  to  interfere  with  motility 
by  contraction  of  the  bands. 

The  radiological  findings  show  stasis  and  often  a  stenotic  point  or 
evidences  of  angulation,  or  a  long  double-barrel  appearance  of  the  colon 
in  some  cases. 

Treatment. — Division  or  separation  of  the  membrane  is  indicated. 

MOVABLE  CECUM 

Movable  cecum  has  been  considered  by  some  as  an  anomaly  of  devel- 
opment (congenital)  as  it  has  been  found  associated  with  Jackson's  mem- 
brane. The  author  finds  that  the  cecum  is  prolapsed  and  is  usually 
atonic  and  dilated  and  believes  it  occurs  chiefly  in  association  with  enter- 
optosis.  Incompetent  ileocecal  valve  is  believed  at  times  to  be  dependent 
on  this  condition  and  it  is  also  thought  to  have  a  bearing  in  the  production 
of  the  ileal  kink.  Fishel  denies  that  mobile  cecum  and  constipation  pro- 
duce the  symptoms,  since  some  of  the  patients  suffer  from  diarrhea, 
but  holds  that  chronic  catarrhal  typhlitis  is  the  cause,  producing  motor 
insufficiency  and  atony,  with  retention  of  contents,  fermentation,  etc. 
J.  A.  Blake^  attributes  the  symptoms  to  the  atonic  condition  and  dilatation 
which  account  for  the  fact  that  fixation  does  not  cure  many  cases.  Un- 
questionably, the  misplaced  cecum  predisposes  to  colitis,  and  even  to 
appendicitis,  in  view  of  its  tendency  to  produce  kinks  in  the  appendix. 

Symptoms. — Among  the  symptoms  of  movable  cecum  are  pain  in  the 
cecal  region  (right  lower  quadrant  of  the  abdomen),  spontaneous  and 
colicky,  or  only  felt  on  palpation  and  also  intermittent,  the  attacks  being 
rather  ill-defined,  or  there  may  be  gurgling  in  that  region  and  evidences 

'  Med.  Rec,  April  4,  1914. 


640  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

of  distention  of  the  cecum  (a  tumor-like  air  cushion  painful  on  deep  palpa- 
tion, marked  by  tympany  and  the  splashing  sound.  The  balloon-like 
cecum  may  be  felt  or  at  times  seen.  Colitis  may  develop,  severe  consti- 
pation or  diarrhea  alternating  with  constipation  occur.  There  are  fre- 
quently nervous  symptoms  resulting  from  chronic  intestinal  putrefaction. 

These  cases  may  be  mistaken  for  appendicitis,  a  normal  appendix  being 
found  at  operation,  or  the  symptoms  may  occur  after  appendectomy, 
much  to  the  discomfort  of  the  patient. 

Diagnosis. — The  :«;-rays  furnish  the  most  accurate  method  of  diagnosis. 
The  cecum  will  be  found  prolapsed  and  often  tipped  over  (oblique).  By 
inflating  the  rectum  with  air  or  CO2  one  can  also  by  percussion  and  pal- 
pation determine  this  condition. 

Treatment. — Medical  treatment  should  first  be  instituted.  A  proper 
supporting  belt,  or  Rose's  adhesive  plaster  belt  for  the  enteroptosis  and 
diet  and  treatment  for  this  condition  should  be  carried  out,  in  addition  to 
appropriate  remedies  for  the  intestinal  putrefaction  and  constipation. 
Some  advocate  fixation  of  the  cecum,  but  Blake  advises  plication  of  the 
cecum  and  ascending  colon.  He  suggests  removal  of  the  cecum,  ascend- 
ing and  part  of  the  transverse  colon  with  ileo-sigmoidostomy  in  severe 
cases  that  have  resisted  all  methods  of  treatment.  R.  T.  Morris'  opera- 
tion is  also  excellent.  On  several  occasions,  when  appendectomy  has  been 
performed  for  chronic  appendicitis,  the  operator  has  performed  fixation 
of  the  cecum  in  cases  of  mine  with  marked  movable  cecum  and 
enteroptosis. 

INCOMPETENCY  OF  THE  ILEOCECAL  VALVE 

Functions  of  the  Ileocecal  Valve. — The  ileocecal  valve  retains  the  mate- 
rial in  the  small  intestine  until  the  digestive  work  is  complete  and  the 
digested  portion  has  been  absorbed.  In  small  successive  amounts,  it 
allows  the  passage  of  undigested  food  residues,  water,  etc.,  into  the  large 
intestine  and  further  prevents  the  reflux  of  material  from  the  colon  into 
the  ileum. 

Under  normal  conditions  one  would  expect  a  competent  ileocecal  valve, 
though  the  writer  has  observed  several  cases  in  which  incompetency  of  the 
valve  was  demonstrated  during  examinations  for  other  conditions,  when 
he  could  impute  no  symptoms  whatever  to  the  valvular  insufficiency.  The 
radiologists  have  made  a  study  of  this  condition  for  some  years  past,  and 
Kellogg^  and  Case^  consider  it  of  grave  pathologic  import. 

Etiology.— Among  the  causes,  Kraus  considers  stretching  or  breaking 
of  the  hebenula  (muscular  longitudinal  band  maintaining  the  partial 
normal  intussusception  of  the  ileum  forming  the  valves)  by  reason  of  over- 
distention  of  the  cecum  and  colon  from  constipation  or  gas  accumulation. 
Distortion  of  the  folds  by  cicatricial  contraction  or  inflammation,  tuber- 
cular disease,  colitis,  atrophy  of  tissue  of  valves  from  inflammation, 
t)rphlitis,  appendicitis  with  adhesions,  movable  cecum  with  atonic  dilata- 
tion of  the  cecum,  and  Lane's  ileal  kink,  though  Kellogg  believes  ileocecal 
incompetency  is  the  cause  of  the  kink.     Temporary  incompetency  may 

^  Med.  Rec,  June  21,  1913;  Surgery,  Gyn.  and  Obstet.,  Nov.,  1913. 
2  Journal  A.  M.  A.,  Oct.  3,  1914;  Med.  Rec,  Mem.,  7,  1914. 


CHRONIC    INTESTINAL    STASIS  64I 

result  from  overdistention  by  accumulation  of  gas  or  liquid  contents  or  of 
an  excessively  large  enema  (Cannon,  Case).  Case  has  observed  that  the 
presence  of  a  foreign  body,  a  string  in  transit,  has  produced  it. 

Symptoms. — Some  claim  that  pain,  faintness  and  nausea  followed  bv 
distention  may  occur  at  the  time  of  commencement  of  ileocecal  incompe- 
tency. Hayes,  under  chronic  ''dilatation  of  the  duodenum,"  describes  a 
method  of  determining  such  incompetency.  Among  symptoms  attributed 
to  incompetency  of  the  ileocecal  valve  are: 

Irritation  and  diarrhea  due  to  passage  of  a  large  amount  of  undigested 
material  from  the  small  intestine,  occur  in  a  small  per  cent,  of  cases. 

Overdistention  of  the  colon,  stasis,  putrefactive  processes,  colitis,  peri- 
colitis or  appendicitis  result.  Development  of  tuberculosis  and  cancer 
may  ensue. 

The  cecal  contents  are  forced  back  into  the  small  intestine  and  the 
accumulation  in  the  small  intestines  acts  as  a  drag  upon  the  root  of  the 
mesentery,  producing  obstruction  at  the  junction  of  the  duodenum  and 
jejunum  and  so  causes  duodenal  and  gastric  stasis.  Then  as  a  result  of 
bacteria  and  toxins  in  the  dilated  duodenum,  we  have  gastritis,  duodenitis, 
gastric  and  duodenal  ulcer,  cholelecystitis,  cholangitis,  gall-stones,  pan- 
creatitis, adhesions  about  the  pylorus  and  duodenum  with  chronic  pain 
in  the  pyloric  region,  and  various  digestive  disturbances.  It  aggravates 
a  Lane's  kink  if  present. 

Gas  regurgitates  into  the  small  intestines  causing  distention,  and  it 
may  oscillate  back  and  forth  between  the  small  and  large  intestine. 

Constipation  with  stagnation  and  feces  resembling  that  of  sheep  occurs. 
The  returned  feces  give  a  putty-like  feel  on  palpation. 

There  is  marked  intestinal  intoxication  with  all  its  symptoms — sallow 
skin,  nervous  symptoms  or  neurasthenia,  arteriosclerosis,  cardio-vascular 
and  renal  disease,  neuritis,  insomnia,  rheumatism,  etc.,  practically  all  the 
symptoms  that  have  been  imputed  by  Lane  to  his  kinks.  I  have  seen  cases 
with  no  clinical  sytnptoms  resulting.  The  condition  is  readily  determined 
by  the  x-rays  by  the  use  of  bismuth,  or  barium  enema.  - 

Treatment. — This  comprises  diet  and  active  regulation  of  the  bowels. 
Chronic  intestinal  putrefaction,  colitis,  etc.,  should  receive  appropriate 
treatment.  With  development  of  special  organisms  in  the  stool,  autogen- 
ous vaccines  are  indicated.  Abdominal  support  is  required  if  there  is 
enteroptosis,  and  surgical  procedure  for  appendicitis,  or  any  other  surgical 
condition.  Kellogg  suggests  revision  of  the  valves  by  a  special  technic, 
in  the  event  of  laparotomy  for  some  other  purpose.     I  do  not  advocate  it. 

Angulations,  Adhesions,  Dilated  Sigmoid. — Various  angulations  may 
occur  in  the  colon,  particularly  as  a  result  of  enteroptosis.  Adhesions  may 
be  associated.  Obstinate  constipation  and  chronic  intestinal  putrefaction 
with  its  symptoms  occur,  plus  the  symptoms  of  splachnoptosis  when  such 
is  present.  The  a;-rays  will  determine  these  conditions  after  the 
method  described  under  determination  of  Jackson's  membrane.  Ap- 
propriate medical^  treatment  is  indicated,  though  at  times  separation  of 
adhesions  may  be  required  and  rarely  enteroenterostomy.     With  a  di- 

^  Rose's  plaster  belt  and  treatment  of  enteroptosis  should  be  employed  when  such 
is  present. 

41 


642  DISEASES   OF   THE   STOMACH    AND   INTESTINES 

lated  and  redundant  sigmoid,  pain,  discomfort,  distention,  obstinate  con- 
stipation and  at  times  colitis  occur. 

In  the  event  of  failure  of  medical  treatment,  operation  may  be  required. 
One  occasionally  sees  cases  of  prolapse  of  the  sigmoid  with  slight  intussus- 
ception into  the  rectum  in  association  with  enteroptosis.  The  writer 
treated  one  such  case  suffering  from  obstinate  colitis  without  success. 
Subsequently  Gant  suspended  the  sigmoid  with  resulting  cure. 


CHAPTER  XXV 

INTESTINAL    CATARRH;    ENTERITIS;    COLITIS;    CATARRHAL 
SIGMOIDITIS;  PROCTITIS;  PHLEGMONOUS  ENTERITIS 

ACUTE  AND  CHRONIC  INTESTINAL  CATARRH 

{Synonyms. — Enteritis;  Catarrhus  Intestinalis) 

Intestinal  catarrh  is  one  of  the  commonest  conditions  with  which 
we  have  to  deal,  and  is  of  importance,  since  in  acute  cases  in  the  young 
or  aged,  it  may  seriously  endanger  the  life  of  the  patient ;  while  the  chronic 
cases  are  often  obstinate  and  difficult  to  cure,  and  may  impair  the  general 
health. 

It  occurs  in  two  types,  the  acute  and  chronic,  and  these  in  turn  may 
be  primary  or  secondary  to  some  other  disease. 

ACUTE  INTESTINAL  CATARRH 

{Synonyms. — Enteritis  Acuta;  Catarrhus  Intestinalis  Acutus;  Cholera  Nostras;  Acute 

Diarrhea) 

Acute  intestinal  catarrh  is  defined  as  an  acute  inflammation  of  the 
intestines,  characterized  by  pains  or  considerable  severity  and  accom- 
panied by  diarrheal  movements  containing  an  admixture  of  mucus.  The 
disease  may  attack  a  portion  of  the  bowel  and  we  may  have  a  duodenitis, 
jejunitis,  ileitis,  colitis,  sigmoiditis,  and  proctitis.  In  many  cases  the 
entire  intestinal  tract  is  involved.  Appendicitis  is  described  in  a  separate 
chapter.  Though  Woodward^  held  that  the  small  intestine  may  not  be 
involved  alone,  yet  it  unquestionably  occurs.  In  many  cases  acute  catarrh 
of  the  colon,  on  the  other  hand,  gives  the  prominent  symptoms,  though 
there  is  frequently  involvement  of  the  ileum.  The  inflammation  may  also 
be  confined  to  the  large  intestine. 

Etiology. — Age. — It  may  occur  at  all  ages,  and  is  frequently  found  in  in- 
fants and  children.  Acute  intestinal  catarrh  may  be  primary  (idiopathic), 
or  secondary  to  some  other  disease. 

Primary  acute  catarrh  is  due  to  the  following  causes:  i.  An  exces- 
sive quantity  of  food,  so  that  a  considerable  portion  remains  undigested 
and  acts  as  a  source  of  irritation;  heavy  and  indigestible  food;  extremely 
cold  drinks,  or  an  idiosyncrasy  to  certain  foods.  In  others,  who  are 
suffering  from  slight  intestinal  disturbances,  some  articles  of  diet  which 
otherwise  would  produce  no  difficulty  may  lead  to  the  development  of 
catarrh.  Unripe  fruit,  tainted  meat,  milk  or  fish,  or  vegetables  that  are 
overripe  or  spoiled.  Auto-intoxication  with  diarrhea  may  result  from 
ingestion  of  such  material ,  and  catarrh  is  frequently  produced,  if  the  source 
of  irritation  is  not  immediately  removed. 

*  Medical  and  Surgical  History  of  the  War  of  the  Rebellion. 
643 


644  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

2.  Chemic  irritants,  both  organic  and  inorganic  substances,  such  as 
colocynth,  croton  oil,  jalap,  senna,  podophyllin,  spices,  pepper,  copaiba, 
mustard,  garlic,  cantharides,  mercury,  arsenic,  lead,  copper,  tartar  emetic, 
phosphorus,  antimony,  alcohol,  chloroform,  ether,  and  some  of  the 
alkaloids,  such  as  colchicin,  veratrin,  acids,  and  alkalis.  With  concen- 
trated irritants  the  mucosa  may  be  permanently  damaged.  Catarrh  is 
caused  when  smaller  quantities  are  ingested. 

3.  Mechanical  irritants,  such  as  hardened  scybalae,  enteroliths,  biliary 
calculi,  foreign  bodies,  such  as  seeds,  fruit-pits,  coins,  etc. 

4.  Exposure  to  cold  or  high  temperature,  especially  in  children  and 
infants,  or  sudden  variation  in  temperature,  wetting  the  feet,  are  predis- 
posing causes;  these  conditions  probably  favor  the  development  of  micro- 
organisms and  the  production  of  circulatory  changes. 

5.  Chemic  irritants  from  the  blood,  such  as  in  catarrhal  nephritis, 
catarrh  from  mercurial  inunction,  or  from  abdominal  burns.  Elimina- 
tion of  the  poisons  through  the  bile  and  from  the  blood  during  intestinal 
secretion  is  the  probable  cause  of  the  catarrh. 

Acute  intestinal  catarrh  may  be  secondary: 

1.  To  general  infection,  as  in  typhoid,  dysentery,  cholera,  sepsis, 
influenza,  pneumonia,  scarlatina,  measles,  malaria,  rheumatism,  or  other 
infectious  diseases. 

~   In  dysentery  and  typhoid  the  ulcerations  are  in  part  responsible. 

2.  Direct  action  of  microorganisms,  as  in  infantile  catarrhs  due  to 
the  activity  of  numerous  types,  such  as  proteus  vulgaris  and  streptococci. 
Bacillus  enteritidis  s'porogenes,^  colon  bacillus,  also  Bacillus  dysenteriae; 
and  myiasis  (larvae  of  flies). 

3.  Extension  of  the  inflammatory  process  from  adjacent  parts,  as  in 
peritonitis,  invagination,  hernia,  tubercular  or  cancerous  ulceration,  and 
thrombosis, 

4.  Diseases  of  the  liver,  heart,  and  lungs  due  to  stasis  and  engorgement. 

5.  In  the  cachexia  of  cancer,  profound  anemia,  diabetes,  Addison's 
and  Bright's  disease,  intestinal  catarrh  may  be  a  terminal  event. 

Morbid  Anatomy. — The  entire  gastro-intestinal  tract  may  be  involved, 
or  only  portions  of  the  intestines  are  affected.  These  differences  depend 
on  the  extent  of  the  catarrhal  process  and  upon  the  cause  and  intensity 
of  the  inflammation.  The  anatomic  changes  are  not  always  commensurate 
with  the  severity  of  the  symptoms. 

The  mucous  membrane  of  the  intestines  is  reddened  uniformly  or  in 
spots,  from  light  red  to  dark  purple  in  color,  especially  marked  around 
the  follicles  and  plaques,  on  the  summit  of  the  valvulae  conniventes  and 
of  the  villi.  If  the  inflammatory  process  is  intense,  extravasations  of 
blood  occur.  The  mucous  membrane  is  swollen  and  edematous,  and  is 
often  covered  with  tenacious  glassy  mucus,  stained  by  bile  or  blood  and 
more  or  less  opaque.  Desquamated  epithelial  cells  and  occasionally  a 
few  pus-cells  are  seen  in  the  mucus  under  the  microscope;  layers  of  epi- 
thelium may  desquamate  and  form  gray  shreds.     Fecal  contents  are 

^  This  was  believed  to  be  possibly  an  impure  culture  of  the  Bacillus  aerogenes 
capsulatus,  though  it  may  be  a  distinct  organism  (Herter,  Bacterial  Infections  of 
the  Digestive  Tract). 


ACUTE  INTESTINAL  CATARRH  645 

usually  liquid.  The  villi  and  solitary  follicles  are  swollen  and  appear  as 
whitish  nodules  surrounded  by  a  red  injected  area  (enteritis  follicularis 
seu  nodularis). 

If  the  process  continues,  these  nodules  may  rupture  and  give  rise  to 
follicular  ulcers.  Catarrhal  ulcers  are  produced  by  loss  of  the  epithelial 
covering  and  extension  of  the  inflammation.  Irritation  in  the  neighbor- 
hood of  these  ulcers  may,  in  protracted  cases,  give  rise  to  polypoid  growths. 

Microscopically,  there  are  congestion  and  distention  of  the  blood-vessels 
of  the  mucosa  and  submucosa  and  small  extravasations  are  at  times  seen 
between  the  glands  of  Lieberkiihn.  The  spaces  between  the  glands  are 
frequently  widened  and  contain  abundant  masses  of  round  cells.  They 
are  also  present  in  the  superficial  or  deeper  layers  of  the  submucosa. 

The  swelling  of  the  solitary  follicles  is  due  to  proliferation  of  their 
cells  and  to  round-cell  infiltration.  This  is  also  true  of  Peyer's  patches 
when  they  are  involved,  which  is  rare  to  any  extent.  The  epithelium  of 
the  mucosa  is  detached,  especially  in  the  large  intestine,  but  this  is 
believed  to  be  chiefly  a  postmortem  change. 

The  epithelium  is  undoubtedly  involved  in  the  catarrhal  process,  as 
degenerated  epithelial  cells  are  found  in  the  mucus  with  the  stool.  The 
cells  of  the  glands  may  be  cloudy  and  swollen. 

Crypts  of  Lieberkiihn. — The  glands  are  enlarged  or  the  fundus  is 
wider  than  normal,  the  opening  is  narrow,  so  that  the  crypt  becomes 
bottle  shaped.  They  may  be  detached  from  their  base  and  raised,  or 
protrude  into  the  intestines,  or  even  desquamate. 

The  submucosa  is  hyperemic.  The  muscular  and  serous  coats  are 
unaffected. 

Symptoms. — They  depend  on  the  etiology,  the  location  of  the  catarrh, 
and  its  severity,  so  that  considerable  variation  occurs.  The  general 
symptoms  of  an  ordinary  primary  attack  are  as  follows: 

It  usually  begins  with  a  feeling  of  fulness  in  the  lower  part  of  the  ab- 
domen, with  attacks  of  colicky  pains  and  diarrhea.  Nausea  and  vomiting 
may  be  associated  with  these  symptoms  at  the  incipiency  of  the  attack. 
In  the  mild  cases  there  may  be  no  temperature,  or  it  may  be  moderate; 
while  in  the  severe  types  there  may  be  a  chill  with  rise  of  temperature  to 
103°  to  io4°F.  In  severe  cases  of  ileocolitis  in  young  children,  as  a  result 
of  intestinal  intoxication,  symptoms  resembling  meningitis  may  occur. 
They  may  suffer  from  somnolence,  convulsions,  trismus,  etc.  Lumbar 
puncture  will  show  there  are  no  cellular  elements  or  microbes.  In  some 
cases  there  may  be  tympanites.  There  are  gurgling  sounds  (borborygmi) 
and  the  abdomen  is  tender  on  pressure,  at  times  over  special  regions 
markedly  so.     Loss  of  appetite  occurs. 

The  number  of  stools  depends  upon  the  severity  of  the  case.  There 
may  be  only  two  or  three  movements  in  twenty-four  hours,  or  as  many 
as  fi,f  teen  to  twenty  evacuations.  The  first  one  or  two  movements  usually 
contain  fecal  matter  and  are  somewhat  mushy  in  character.  They 
rapidly  become  semifluid,  and  finally  thin  and  liquid.  Feces  and  scybala; 
may  be  found  later.  The  more  the  colon  is  involved,  the  greater  is  the 
diarrhea.  Diarrhea  does  not  always  occur  if  the  small  intestine  alone  is 
the  seat  of  inflammation.    The  early  stools  are  frequently  of  a  dark  brown 


646  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

color,  sometimes  of  offensive  odor,  the  latter  condition  being  especially 
noticeable  if  dietetic  errors  are  the  cause. 

The  amount  of  material  passed,  exceeds  the  quantity  of  food  ingested, 
due  to  the  digestive  secretions  and  catarrhal  secretion,  all  of  which  are 
rapidly  evacuated.  When  the  stools  consist  of  watery  discharge  and 
mucus  there  is  often  little  or  no  odor.  They  are  slightly  acid  in  reaction 
and  foam-like  in  appearance. 

The  stools  may  be  light  yellow  in  color,  grayish,  or  even  greenish  in 
young  children,  or  colorless,  resembling  rice-water.  These  differences 
in  color  are  dependent  upon  the  location  of  the  catarrh.  In  the  yellow 
fecal  material  Gmelin's  reaction  for  bile-pigment  can  often  be  obtained, 
and  this  is  also  found  in  the  green  movements,  demonstrating  involve- 
ment of  the  small  intestine.  The  colorless  stools  most  frequently  occur 
in  the  specific  choleraic  types. 

With  duodenitis  alone,  or  associated  with  gastritis,  when  there  is  con- 
siderable duodenal  catarrh  and  interference  with  the  escape  of  bile,  there 
may  he  jaundice,  the  presence  of  bile,  and  indican  in  the  urine,  at  times 
albumin  and  casts,  and  the  whitish  stools  found  with  jaundice. 

Mucus  is  contained  in  the  stools.  It  may  float  on  top  of  the  dejec- 
tions in  shreds  of  various  sizes  and  be  of  glassy  appearance,  or  be  stained 
in  various  colors,  or  mixed  with  the  bowel  contents  and  form  a  jelly-like 
mass;  it  may  coat  the  feces  or  be  mixed  with  it  in  small  amounts;  or  the 
movement  may  consist  chiefly  of  mucus.  In  some  cases  the  mucus  may 
only  be  determined  by  the  microscope. 

The  localization  of  the  seat  of  the  catarrh  is  shown  by  the  character- 
istics of  the  mucus,  to  be  described  later. 

Microscopically,  there  are  epithelial  cells,  numerous  microorganisms, 
mucus,  occasionally  a  little  pus  and  blood,  and  undigested  food  particles 
in  the  stool.  Blood  is  found  only  in  severe  cases  where  there  is  marked 
congestion  or  ulceration,  and  pus  when  ulceration  is  present. 

Chemically,  peptones  and  sugar  may  be  present  in  the  dejecta. 

Macroscopically,  food  remnants  may  be  seen  with  the  naked  eye  for 
several  days,  especially  if  dietetic  indiscretion  be  a  factor. 

Subjective  Symptoms. — In  the  milder  cases,  except  for  the  colicky  pains, 
diarrhea,  and  the  feeling  of  pressure  and  fulness,  the  patients  may  not 
feel  very  badly.  In  more  severe  cases  they  may  feel  chilly,  feverish, 
dizzy,  and  weak,  at  times  nauseated,  and  in  some  cases  they  may  vomit. 
Tenesmus  may  be  present  if  the  lower  part  of  the  colon  or  rectum  are 
affected.  Gas  may  be  expelled.  Borborygmi  may  be  audible.  With 
children  and  elderly  persons  the  symptoms  are  often  pronounced.  Col- 
lapse may  occur.  With  infants  the  hydrencephaloid  condition  may 
occur,  temperature  io4°F.  or  more,  sunken  fontanels,  rapid  pulse,  cold 
extremities,  collapse,  etc. 

General  Physical  Signs. — The  abdomen  may  be  bloated,  but  when 
gas  is  expelled  the  distention  lessens  or  disappears.  Splashing  sounds 
can  often  be  elicited.  Over  the  abdomen  usually  there  is  tenderness  on 
palpation,  especially  in  the  region  of  the  navel,  and  frequently  in  the  right 
or  left  iliac  regions,  or  along  the  course  of  the  transverse  colon;  gurgling 
sounds  can  often  be  heard  on  palpation.     In  thin  subjects,  peristaltic 


ACUTE  INTESTINAL  CATARRH  647 

movements  of  the  small  intestine  may  be  visible  either  before  or  after 
palpation. 

If  there  is  much  gas,  there  is  a  tympanitic  note  on  percussion;  it  may 
be  dull  in  character  if  much  fluid  be  present.  Large  accumulations  of 
gas  are  not  frequent. 

Fever. — There  may  be  no  temperature  or  only  moderate  fever.  In 
severe  types  the  temperature  may  be  quite  high  (102°  to  io4°F.).  In 
some  cases  there  are  chills  associated  with  the  fever,  but  the  temperature 
has  a  tendency  to  fall  after  a  few  days  and  does  not  show  the  characteristic 
steady  increase  of  typhoid  fever.  With  tainted  food  or  bacterial  infection, 
fever  is  especially  apt  to  occur.  Such  cases  run  an  acute  course  with 
severe  clinical  symptoms.  Undoubtedly  auto-intoxication  is  a  prominent 
factor  in  their  production. 

With  gastroduodenitis,  jaundice  is  present,  and  often  vomiting. 

Urine  may  become  scanty  and  concentrated,  especially  in  severe 
cases  where  there  are  frequent  movements,  and  there  may  be  found 
cylindroids,  albumin  in  small  amounts,  and  hyaline  casts.  Indican  is 
often  present,  especially  if  the  small  intestine  is  involved,  and  bile,  if 
jaundice. 

Rosenbach's  reaction  (Burgundy  red),  on  boiling  urine  with  nitric 
acid,  is  also  found.  This  also  shows  intestinal  putrefaction.  Acetone 
has  been  found. 

Localization  of  Acute  Catarrh. — Involvement  of  the  small  intestine 
alone  is  more  uncommon,  and  is  usually  associated  with  gastritis. 

I  believe  in  cu:ute  cases  the  involvement  of  the  small  intestine  is  a 
more  frequent  occurrence  than  some  suppose;  though  the  intensity  of  the 
inflammation  may  be  greater  in  one  portion  of  it,  and  in  addition  in  some 
cases  there  may  be  an  especially  severe  inflammation  in  the  colon.  Some 
believe  the  large  intestine  alone  is  most  frequently  involved.  This  is  more 
so  in  chronic  cases.     In  the  rectum  local  involvement  is  quite  frequent. 

Acute  catarrh  of  the  caput  coli,  due  to  fecal  accumulation,  at  times 
occurs,  and  this  must  be  differentiated  from  appendicitis.  The  fecal 
tumor  can  be  generally  discovered  by  the  doughy  feel  on  palpation. 
The  acute  symptoms  subside  rapidly  under  intestinal  irrigation  and 
catharsis. 

This  refers  to  a  simple  catarrh  and  not  to  a  true  typhlitis  which  in- 
volves the  muscular  tissue.  Acute  catarrh  may  occur  in  the  sigmoid  and 
should  be  classified  as  catarrhal  sigmoiditis.  In  sigmoiditis  or  perisig- 
moiditis the  musculature  is  also  involved.  The  cases  described  by  Mayor 
and  Leube  are  evidently  of  this  t)T)e.  Diverticulitis  belongs  to  this  last 
class.     The  nomenclature  should  be  very  specific. 

Localized  Physical  Signs. — An  acute  duodenitis  is  usually  associated 
with  acute  gastritis,  and  we  have  jaundice  with  local  tenderness  on  pressure 
in  the  right  portion  of  the  epigastric  region.  Inflammation  of  the 
duodenum  with  local  tenderness  may  occur  after  cutaneous  burns. 

Tenderness  on  pressure  (pain),  confined  to  the  middle  of  the  abdomen 
and  not  laterally,  shows  the  affection  to  be  probably  confined  to  the 
other  portions  of  the  small  intestine;  but  when  the  small  intestine  alone 
is  involved,  as  diarrhea  is  usually  absent,  the  diagnosis  is  difl5cult.    The 


648  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

presence  of  a  considerable  number  of  undigested  food  particles  and 
epithelial  cells  tinged  with  yellow  bile-pigment  in  the  feces;  microscopic 
mucus  mixed  with  the  stool,  with  rarely  a  small  amount  of  visible  mucus, 
are  a  valuable  aid  to  the  diagnosis.     Indican  is  usually  present  in  the  urine. 

Acute  Colitis. — With  acute  colitis^  the  pain  and  tenderness  are  most 
marked  along  the  course  of  the  colon,  over  the  cecum,  transverse  or  de- 
scending colon,  sigmoid  flexure,  or  over  all  together.  The  stools  are 
diarrheal  and  contain  considerable  mucus. 

Proctitis  is  characterized  by  tenesmus  and  colicky  pains  in  the  left 
iliac  fossa.  There  is  a  constant  desire  to  defecate.  The  scybalae  or  stools 
are  surrounded  with  mucus,  sometimes  tinged  with  blood,  and  the  mucous 
membrane  may  prolapse  during  defecation  and  is  red  and  tender.  Rectal 
digital  examination  is  accompanied  by  much  pain,  and  the  examining 
finger  shows,  at  times,  traces  of  blood. 

The  most  important  method  of  diagnosis  to  localize  the  process  is  b\- 
examination  of  the  feces,  noting  the  character  of  the  mucus.  Macroscopic 
examination  is  often  sufficient. 

When  pure  mucus  is  passed  without  any  fecal  admixture,  catarrh  of 
the  rectum,  sigmoid,  or  of  the  descending  colon  is  indicated. 

If  small  masses  of  fecal  matter  or  soHd  balls  are  passed  covered  with 
a  layer  of  mucus,  the  same  condition  is  indicated. 

If  there  is  catarrh  of  the  entire  large  intestine  up  to  the  cecum,  even 
if  the  movements  are  thin,  shreds  of  mucus  are  intimately  mixed  with 
the  fecal  matter,  and  can  be  recognized  by  the  naked  eye. 

The  close  admixture  of  fecal  material  and  mucus  distinguish  it  from 
catarrh  of  the  lower  colon. 

In  catarrh  of  the  upper  colon  alone  or  of  the  small  intestine,  or  small 
intestine  and  upper  colon  alone,  usually  no  mucus  can  be  seen  with  the 
naked  eye,  and  hyaline  microscopic  lumps  of  mucus  are  found  intimately 
mixed  with  the  stools.  Small  amounts  mixed  in  the  feces  are  at  times 
visible. 

Diagnosis. — If  a  colon-tube  be  introduced  high  into  the  rectum,  and 
lavage  be  carried  out  intermittently  with  warm  water  through  a  funnel, 
by  the  same  method  as  lavage  of  the  stomach,  the  recovered  fluid  will 
contain  visible  mucus,  and  demonstrate  that  catarrh  of  the  large  intestine 
is  present.     This  method  was  suggested  by  Boas. 

The  presence  of  yellow  mucous  granules  in  the  movements  has  been 
considered  diagnostic  of  inflammation  in  the  small  intestine,  though 
Schmidt  and  Boas  believe  them  to  be  structureless  remains  of  muscle 
substance,  casein,  or  egg-albumen,  colored  with  bile-pigment. 

Bile-pigment. — If  the  bile-pigment  reaction  can  be  obtained  in  the 
stool  or  in  some  of  its  constituents,  this  indicates  an  inflammation  of  the 
small  intestine,  and  the  more  marked  the  reaction,  the  higher  up  the 
involvement.  It  may  be  found  in  the  mucus,  and  this  may  be  stained 
a  dark  orange,  green,  or  greenish  yellow. 

Cylindric  epithelium,  round  cells,  or  rarely  fat  (droplets)  may  be 
stained  yellow. 

^  More  properly,  acute  catarrhal  colitis,  to  distinguish  it  from  dysenteric  and 
other  types. 


ACUTE  INTESTINAL  CATARRH  649 

An  acid  reaction  of  the  stool  also  shows  involvement  of  the  small  intestine. 

Boas  has  subjected  a  filtrate  of  the  feces  to  the  digestion  test  with  a 
small  piece  of  albumin,  and,  when  the  result  is  positive,  justly  concludes 
that  the  condition  originates  in  the  small  intestine. 

Duration. — Mild  cases  may  rapidly  recover  in  three  to  five  days,  while 
severe  cases  often  continue  for  several  weeks.  The  intestines  remain 
susceptible  to  irritation  for  a  considerable  time,  and  errors  in  diet  may 
cause  a  recurrence  of  the  attack.  The  condition  may  become  chronic. 
Constipation  may  follow  the  acute  attack,  and  this  should  carefully  be 
treated,  lest  habitual  constipation  develop.  The  acute  attack  may  never 
be  entirely  recovered  from,  but  gradually  develop  into  a  chronic  catarrh. 

Prognosis. — These  cases  frequently  recover  within  a  short  time,  but 
in  children  or  very  old  and  enfeebled  persons,  the  disease  may  occasionally 
prove  fatal.  The  prognosis  as  to  cure  depends  upon  the  etiology  of  the 
disease;  thus,  if  due  to  chemic  irritants,  the  condition  may  become  chronic. 

Treatment. — Prophylaxis. — Particular  articles  of  food  or  drink  known 
to  produce  attacks  of  acute  intestinal  catarrh  should  always  be  avoided. 
Some  are  affected  by  ice-cream  and  ice-cold  drinks,  and  these  should  be 
forbidden.  Exposure  to  cold  or  wet  should  be  avoided.  Rest  in  bed 
should  be  enjoined. 

When  tainted  food  has  been  ingested,  or  indigestible,  or  an  excessive 
amount  of  food,  even  though  there  is  diarrhea,  a  laxative  should  be  given 
immediately  to  thoroughly  empty  the  bowel. 

Calomel,  5  to  10  grains  (0.3-0.6),  followed  by  a  saline  cathartic, 
preferably  within  six  hours  for  .rapid  effect,  or  castor  oil  or  laxol,  i  to  2 
ounces  (30.0-60.0),  should  be  given  to  an  adult.  Castor  oil  may  be 
administered  in  coffee,  sarsaparilla,  ginger  ale,  or  with  orange  or  lemon 
juice. 

For  infants  and  young  children  calomel,  }-i  to  i  grain  (0.32-0.65), 
in  divided  doses,  or  i  to  i}4  drams  (4.0-^.0)  of  castor  oil,  or,  pfreferably, 
laxol. 

If  an  acid  chemic  irritant  has  been  taken,  then  an  alkali  should  be 
given,  and  vice  versa.  Antidotes  should  be  administered  in  the  case  of 
chemic  poison.  It  is  preferable  also  to  administer  a  cathartic,  so  as  to 
remove  the  poison  from  the  intestinal  canal. 

Enteroclysis  with  normal  saline  solution  at  110°  to  ii5°F.  is  indicated 
in  all  these  cases,  employing  i  gallon  (4  liters)  by  the  recurrent  method, 
so  as  to  thoroughly  cleanse  the  large  intestine. 

Calomel  is  useful  when  there  are  flatulence  and  indicanuria.  I  prefer 
a  fairly  large  initial  dose  in  these  cases,  and  to  repeat  it  within  a  few  days, 
to  the  method  of  daily  small  doses.  There  is  some  danger  of  salivation 
from  frequent  small  doses.  Colonic  irrigation  once  or  twice  a  day  is  of 
great  importance. 

These  methods,  combined  with  salol  or  beta-naphthol-bismuth 
(orphol),  5  grains  (0.3),  three  or  four  times  a  day,  with  the  other  bismuth 
preparations,  or  with  hexamethylenamin,  5  grains  (0.3),  and  sodium  ben- 
zoate,  10  grains  (0.6),  t.i.d.,  are  generally  sufficient. 

Dilute  hydrochloric  acid  in  lo-minim  (0.59)  doses  t.i.d.  is  an  ex- 
cellent adjunct,  providing  there  be  no  nausea  or  vomiting;  oxyntin  cap- 


650  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

sules  with  nux  vomica  may  be  substituted.  Resorcin,  5  grains  (0.3) 
t.i.d.,  may  be  employed  for  intestinal  fermentation.  One  of  the  best 
remedies  for  diarrhea  is  bismuth. 

Bismuth  subnitrate,  20  to  30  to  40  grains  (1.3-2.0-2.6),  given  four 
or  five  times  a  day,  is  of  service.  It  may  be  combined  with  saccharated 
pepsin  as  a  vehicle  in  mild  cases  in  smaller  doses;  thus: 

Bismuth  subnitrate,  saccharated  pepsin,  equal  parts,  K  to  ^  tea- 
spoonful  every  two  or  three  to  four  hours  during  the  twenty-four  hours. 

Bismuth  subcarbonate,  15  to  30  grains  (i.a-2.0),  four  times  a  day. 

Bismuth  subgallate,  5  grains  (0.3),  three  or  four  times  daily  with  the 
bismuth  subnitrate,  is  excellent. 

Bismuth  salicylate,  5  grains  (0.3),  four  times  a  day  is  a  good  anti- 
fermentative;  or  ichthoform,  5  grains  (0.3)  t.i.d.,  in  combination  with 
bismuth  subnitrate.     Ichthalbin,  5  grains  (0.3)  t.i.d.,  is  useful. 

Tannalbin,  tannigen,  or  tannopin,  5  to  10  grains  (0.3-0.6),  can  be 
used  in  combination  with  bismuth. 

I^.  Bismuth,  subnit 3ss  (16.0) 

Mist,  cretae q.  s.  5iv  (125.0). — M. 

Sig. — Shake.  One  to  two  teaspoonf  uls  in  water  every  two  orthree  hours. 
The  same  prescription,  with  10  to  15  drops  (0.6-1.0)  of  tincture  opii 
camphor,  in  each  dram  dose,  is  useful  if  the  diarrhea  continues  excessive. 

The  following  represent  single  doses  of  remedies  which  can  be  taken 
every  three  or  four  hours  in  persistent  diarrhea: 

I^.  Tinct.  opii TC[x  (0.59) 

Tinct.  kino  '  --  m       /      o\ 

^  . .     ^       ,     ,        aa  TTlxx  (1.18) 

Comp.  tmct.  catechu  j 

Aqua  destil q.  s.   3ij  (8.0). — M. 

I^.  Tinct.  opii T[[x  (0.59) 

Mist,  cretae 3  J  (4-o) 

Comp.  tinct.  catechu q.  s.   Sij  (8.0). — M. 

I^.  Bismuth,  subnit gr.  x  (0.6) 

Tinct.  opii  deodor TUx  (0.59) 

Aq.  cinnamomi q.  s.   3  j  (4-o)- — M. 

I  prefer,  however,  to  avoid  opiates  as  much  as  possible  in  my  treatment. 

Cotoin,  I  to  2  grains  (0.06-0.1);  tincture  coto,  15  minims  (0.888), 
or  paracotoin,  in  double  dose  as  compared  to  the  cotoin,  have  been 
suggested  for  diarrhea. 

Codein,  M  to  3^  grain  (0.008-0.016),  or,  rarely,  morphin  may  be 
required.     Patient  should  be  kept  in  bed. 

Heat. — Dry  or  moist  heat,  or  Priessnitz  compress,  hot-water  bag, 
flaxseed,  or  milk  or  potato  poultice,  hot  pieplate,  hot  salt-bag,  compress 
of  hot  water,  pepper  poultice,  weak  mustard  and  flour  poultice  should  be 
applied.  If  there  are  symptoms  of  collapse,  warmth,  hot  drinks,  camphor 
hypodermics,  camphor  gr.  v  in  lUx  sterile  almond  oil,  and  strychnin  gr. 
Ho>  are  indicated^.   Hypodermoclysis  may  be  required. 

Enteroclysis  is  useful  to  rid  the  bowel  of  irritating  material,  and  for 
treatment  of  the  acute  catarrh  when  located  in  the  colon.  It  may  be 
given  by  enema  or,  preferably,  with  the  recurrent  tube.     About  i  to  i>^ 

^  The  cardiac  stimulants  can  be  given  alone  or  together,  every  4  to  6  hours. 


ACUTE  INTESTINAL  CATARRH  65 1 

quarts  (100&-1500  c.c.)  should  be  used  by  enema,  hips  elevated,  injecting 
with  a  long  tube. 

When  there  is  marked  fermentation — 

Acetozone i :  2000  to  i  :  1000; 

Alphazone i :  2000  to  i  :  1000; 

Peroxid  of  hydrogen 3  J  (30-0)  to  2  quart^  (liters),  or 

Salicylic  acid  (i  :  1000) 2  quarts  (liters) ; 

Boric  acid 3  J  (4-°)  to  2  quarts  (liters) ; 

Permanganate  of  potash i :  3000. 

Irrigate  with  2  or  3  quarts  (liters)  with  a  recurrent  tube  once  a  day. 

Soothing '  irrigations  are  flaxseed  tea,  gum-arabic  solution  in  water 
at  iio°F.,  slippery-elm  water,  or  normal  saline  solution. 

Occasionally  astringent  irrigations  may  be  necessary. 

First  wash  the  bowel  with  warm  water,  then  inject  tannic  acid,  30 
grains  (2.0)  to  i  liter  (quart),  and  15  drops  (0.888)  of  laudanum,  and  hold 
a  while.  Weak  nitrate  of  silver,  5  grains  (0.3)  to  i  quart  (liter),  has  also 
been  recommended,  but  is  better  in  chronic  cases.  Protargol  or  argy- 
rol  I  :  3000  has  also  been  employed  but  is  also  preferable  for  chronic  cases. 
Gastritis,  jaundice,  and  malaria  should  be  treated,  if  present,  or  any 
disease  to  which  the  intestinal  catarrh  is  secondary. 

In  referring  to  the  cases  of  dtwdenUis  with  jaundice,  the  author  wishes 
to  impress  on  his  readers  the  value  of  hexamethylenamin  and  sodium 
benzoate.  These  should  be  given  in  doses,  10  grains  each,  dissolved  in 
water,  by  rectum,  if  acute  gastritis  is  present,  and  in  5  grains  (0.3)  each,^ 
when  this  has  subsided.  These  remedies  have  an  excellent  effect  on  the 
severe  indicanuria  which  I  usually  found  present,  and  the  hexamethylen- 
amin disinfects  the  biliary  tract,  and  I  believe  prevents  cholecystitis 
and  other  biliary  infections.  The  writer  always  uses  these  methods. 
High  enemata  or  irrigation  with  hot  normal  salt  solution  are  of  value. 
Occasionally  cold  enemata  may  be  used.  The  sour  milks  are,  moreover, 
of  great  value. 

If  acute  gastritis  accompanies  the  acute  duodenitis,  the  former  con- 
dition must  receive  particular  attention,  since  remedies  directed  to  the 
obstructive  jaundice  (duodenal)  would  not  be  retained.  External  heat 
should  be  kept  on  continuously,  occasionally  a  mustard  poultice,  and  soda 
bicarbonate  given  at  first  in  small  doses,  5  grains  (0.3),  to  liquefy  the 
bile.  When  the  acute  gastric  condition  has  subsided,  the  soda  bicarbonate 
can  be  increased  to  15  grains  (i.o),  or  more  t.i.d.,  and  later,  salicylate 
of  soda,  5  grains  (0.3)  in  capsules,  can  be  substituted  t.i.d.  for  the  soda. 
The  following  prescriptions  aid  intestinal  digestion,  and  the  sodium  suc- 
cinate has  an  excellent  effect  on  the  biliary  tract.  They  represent  a 
single  dose  in  capsule: 

I^.     Holadin gr.  iij  (0.198); 

Succinate  of  soda gr.  v  (0.3) ; 

Bile  salts  (Fairchild) gr.  ss  (0.033). — M. 

I^.'    Holadin gr.  ij  (0.132); 

Bile  salts gr.  ss  (0.033); 

Phenolphthalein gr.  j  (0.066). — M. 

1  They  are  then  given  by  mouth. 


652  DISEASES    OF    THE    STOMACH    AXD    INTESTINES 

I^.     Bile  salts gr.  j  (0.066) ; 

Succinate  of  soda gr.  v  (0.3); 

Phenolphthalein gr.  ss  (0.033). — ^^• 

Sig. — One  capsule  before  meals  or  at  bedtime. 

Olive  oil,  \-2  to  i  ounce  (30.0-60.0)  t.i.d.,  is  of  value  when  it  can  be 
retained.     Oleic  acid,  5  minims  (0.3)  in  capsule,  can  be  substituted. 

Diet. — Cold  drinks  should  be  avoided. 

Warm  teas,  such  as  chamomile,  fennel,  anise  seed,  or  plain  tea  and 
gruels  (barley  or  rice),  with  or  without  milk,  very  dilute  milk  with  lime- 
water,  etc.,  should  be  given.  Milk  is  often  indigestible  and  gruels  are 
preferable. 

Later,  bouillon,  water  soup  (bread  softened  in  hot  water  with  butter 
and  salt),  yolk  of  egg  or  white,  or  entire  egg  (raw  or  soft  boiled),  stale 
bread,  boiled  water,  etc.  Avoid  carbonated  waters.  Vichy  and  milk 
may  be  given  if  the  gas  is  allowed  to  pass  off  before  drinking. 

As  soon  as  the  diarrhea  is  over,  soft-boiled  eggs,  calves'  brains,  scraped 
beef,  mashed  potatoes,  cocoa,  weak  coffed,  chicken,  chops,  steak,  stale 
bread  and  butter,  potatoes  mashed  or  baked  can  be  given.  Fruit,  green 
vegetables,  hot  breads,  fat,  and  acids  should  be  avoided  for  a  considerable 
period. 

CHRONIC  CATARRB  OF  THE  mXESTINES;  CHRONIC  COLITIS 

{Synonyms. — Enteritis  Chronica;  Chronic  Enterocolitis) 

This  disease  is  characterized  by  a  chronic  inflammation  of  the  mucous 
membrane  of  the  intestines,  which  gives  rise  to  various  functional  dis- 
turbances of  the  bowels.     Any  portion  may  be  affected. 

Etiology. — Chronic  intestinal  catarrh  may  arise  from  an  acute  enteritis 
which  shows  no  tendency  to  recovery,  or  more  frequently  from  repeated 
attacks  of  acute  catarrh  which  follow  each  other  at  short  intervals  before 
complete  recovery  occurs.  Patients  frequently  pay  no  attention  to  an 
apparently  mild  attack  and  disregard  the  rules  of  diet  prescribed.  As  a 
result,  the  condition  becomes  chronic. 

In  other  cases,  however,  chronic  catarrh  may  have  an  insidious  onset 
from  the  beginning.  Fecal  accumulation,  notably  scybalae,  may  be  a 
cause  of  a  subacute  or  chronic  catarrh.  Pressure  of  tumors  narrowing 
the  canal,  as  pressure  from  fibroids  of  the  uterus  or  adhesions,  may  be 
factors. 

The  direct  causes  of  chronic  enteritis  are  the  same  as  in  the  acute  type, 
and  chronic  catarrh  may  be  either  primary  (idiopathic)  or  secondary  to 
other  affections.  For  the  complete  etiology  the  reader  should  refer  to 
the  causes  of  acute  intestinal  catarrh. 

Chronic  catarrh  may  be  secondary  to  diseases  of  the  lungs,  especially 
tuberculosis,  and  also  diseases  of  the  liver,  heart,  kidneys,  and  diabetes. 
Intestinal  parasites,  tapeworms,  round- worms,  seat- worms,  etc.,  may  be 
causes  by  producing  irritation.  I  recently  attended  a  case  of  splanchnop- 
tosis, in  which  there  was  marked  prolapse  of  the  sigmoid  flexure  with  a 
tendency  to  fecal  accumulation  therein.  The  patient  never  had  an  acute 
enteritis,  but  for  five  years  has  had  discomfort  in  this  region,  and  in- 
variably every  few  days  the  passage  of  strings  of  mucus  and  scybalae. 


CHRONIC    CATARRH    OF    THE    INTESTINES  653 

There  were  no  symptoms  of  mucous  colic.  The  case  was  one  of  chronic 
catarrh  of  the  sigmoid.  The  symptoms  disappeared  under  treatment  for 
\'isceroptosis.  The  possibiUty  of  chronic  localized  catarrh  from  viscero- 
ptosis, associated  with  fecal  accumulation,  is  worthy  of  consideration. 
Chronic  appendicitis  is  suggested  as  a  cause  by  G.  R.  Lockwood,  and  the 
cure  of  chronic  colitis  has  followed  appendectomy. 

The  rectum  should  always  he  examined.  Pressure  on  the  rectum  from 
a  uterine  fibroid  I  have  seen  produce  partial  stenosis  with  coprostasis 
above,  and  resulting  intestinal  catarrh.  Ulcer,  fissure,  or  hemorrhoids 
may  cause  not  only  local  manifestations,  but  catarrh  higher  up.  I  have 
seen  a  case  with  chief  symptoms  pointing  to  the  descending  colon  and 
sigmoid,  in  which  an  ulcer  high  in  the  rectum  was  the  cause. 

Morbid  Anatomy. — The  anatomic  changes  in  chronic  enteritis  are 
similar  to  those  in  acute  cases,  being  characterized  by  hyperemia,  swelling 
of  the  mucous  membrane,  and  increased  secretion  of  mucus.  The  color 
of  the  mucosa  varies  from  a  dark  venous  red  to  a  pale  grayish-red  tint; 
in  some  cases  it  may  even  be  gray  or  slate  colored  from  extravasation  of 
jiigment  between  the  glands  and  at  the  tips  of  the  villi.  The  last  cases 
are  those  of  long  duration. 

The  surface  of  the  mucous  membrane  is  covered  with  a  transparent 
viscid  mucus  and  the  epithelial  cells  are  cloudy,  in  a  condition  of  fatty 
degeneration,  and  partly  desquamated.  In  the  majority  of  cases  of 
chronic  catarrh  the  accumulations  of  round  cells  (which  are  characteristic 
of  the  acute  type)  are  not  seen,  but  there  is  connective-tissue  proliferation 
in  the  chronic  form. 

Exceptions. — In  some  of  the  early  cases  of  chronic  enteritis  the  micro- 
scopic picture  may  be  much  the  same  as  in  the  acute  process;  and  in 
other  mild  cases  the  only  abnormality  determined  is  the  accumulation  of 
pigment  between  the  glands,  or  in  the  muscularis  mucosae  and  a  slight 
widening  of  the  interstices. 

As  a  result  of  chronic  enteritis,  hypertrophy,  or  atrophy  of  the  intestinal 
mucosa  may  develop. 

Hypertrophy  of  the  Intestinal  Mucosa. — The  glands  of  the  mucosa  are 
elongated,  tortuous,  irregular  in  shape,  and  may  form  diverticula.  Their 
orifices  may  become  occluded  through  connective-tissue  proliferation 
and  there  will  be  a  retention  of  secretion  and  the  formation  of  cysts 
(enteritis  chronica  cystica).  Connective-tissue  proliferation  leads  to  the 
formation  of  pol^-pi  (enteritis  polyposa),  which  are  more  rare,  and  are 
usually  found  in  the  large  intestine.  In  many  cases  the  walls  of  the 
intestines  may  become  thickened  throughout,  including  the  muscular  coat, 
to  the  extent  of  several  times  its  normal  thickness. 

Woodward  reports  a  few  cases  of  proliferation  of  the  intestinal  mucosa 
with  its  glands.  ^ 

Atrophy  of  the  Intestinal  Mucosa. — The  clinical  entity  of  atrophy  of 
the  intestines  has  been  in  considerable  dispute,  and  undoubtedly  a  pseudo- 
atrophy  due  to  postmortem  change  occurs. 

Riegel,  Ewald,  and  Einhorn  believe  there  is  a  true  intestinal  atrophy. 
In  view  of  the  existence  of  an  atrophy  of  the  gastric  mucosa  resulting 
from  a  chronic  gastritis  and  from  its  occurrence  in  pernicious  anemia,  I 


654  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

am  convinced  that  an  atrophy  of  the  intestinal  mucosa  may  occur  in  ad- 
vanced cases  of  chronic  intestinal  catarrh.  The  condition  I  beheve  to  be 
rare.  Such  atrophy  may  originate  in  the  glandular  tissue  in  the  glands 
of  Lieberkiihn.  There  may  be  an  infiltration  of  round  cells,  a  fatty  de- 
generation, a  disintegration,  and  desquamation  or  atrophy.  On  the 
other  hand,  it  may  result  from  a  connective-tissue  proliferation  compressing 
the  glands. 

Musgrave  believes  an  atrophic  condition  of  the  intestines  may  follow 
the  chronic  catarrh  occurring  with  amebic  dysentery. 

The  villi  degenerate  with  the  atrophy  of  the  glands,  shrink,  and  become 
small.  No  ulceration  of  the  solitary  or  agminate  follicles  occurs,  and  it  is 
a  question  whether  atrophy  to  any  extent  ever  takes  place  in  them. 

There  is  a  degeneration  of  the  miiscular  coat  and  some  thinning  of  it. 

Jiirgens^  has  described  a  fatty  degeneration  of  Meissner's  and  Auer- 
bach's  plexus  and  of  the  muscular  tissue,  as  a  special  type  of  intestinal 
atrophy;  Sasaki  records  two  similar  cases  dying  with  the  clinical  symptoms 
of  pernicious  anemia.  These  conditions  probably  are  related  to  intestinal 
atrophy. 

Atrophy  of  the  mucosa  occurs  more  frequently  in  the  colon,  especially 
in  the  cecum,  ascending  colon,  or  ileum  near  the  valve.  Large  portions 
of  the  intestines  are  rarely  found  atrophied,  but  the  process  generally 
involves  certain  parts. 

Ulcerated  Processes. — As  in  acute  enteritis,  we  may  have  ulcerative 
processes  in  chronic  catarrh  of  the  intestines.  Superficial  erosions  of  the 
mucosa  may  become  deeper  with  the  production  of  ulcers.  Rarely  they 
increase  sufficiently  in  depth,  and  resvdt  in  erosion  of  a  blood-vessel  with 
hemorrhage,  or  cause  a  local  peritonitis  with  or  without  abscess,  or  even 
a  perforative  peritonitis.  Generally  the  ulcers  remain  unchanged  for  a 
considerable  time,  or  cicatrize;  occasionally  stricture  of  the  intestines  may 
result.  The  follicles  may  occasionally  swell  up  and  burst,  producing  small 
follicular  ulcers.  Frequently  healing  takes  place.  Extensive  ulcerations 
are  seldom  met  with  in  chronic  enteritis,  unless  accompanying  a  tubercular 
process. 

The  "  sago  grains  "  or  frog  spawn  in  the  feces,  formerly  believed  pathog- 
nomonic of  follicular  ulceration,  are  shown  to  be  of  vegetable  origin. 

Kitagawa  finds  that  some  of  these  grains  are  mucous  in  character,  but 
this  in  itself  militates  against  ulceration,  as  ulcers  do  not  discharge 
mucus,  but  pus.     The  presence  of  mucus  merely  indicates  catarrh. 

Symptoms. — The  chief  diagnostic  symptoms  of  chronic  intestinal 
catarrh  is  the  abnormal  character  of  the  feces.  It  seems  advisable  to  first 
describe  the  subjective  and  objective  symptoms  which  occur  in  many 
cases.  Some  patients  complain  of  no  subjective  symptoms  whatever. 
The  majority  of  cases  complain  of  a  feeling  of  discomfort  or  occasionally 
of  slight  pains  in  the  abdomen.  These  symptoms  are  apt  to  be  most 
marked  after  eating,  usually  several  hours;  or  frequently  just  before  or 
even  after  defecation.  At  times  these  sensations  may  disturb  the  patient 
an  hour  or  two  before  rising. 

There  is  a  feeling  of  tension  or  bloating  of  the  abdomen  which  may 
^  Berlin,  klin.  Wochenschr.,  1892,  p.  357. 


CHRONIC  CATARRH  OF  THE  INTESTINES  655 

be  relieved  by  the  passage  of  flatus,  and  this  tendency  gives  rise  to  con- 
siderable annoyance.  Flatulence  may  become  so  severe  as  to  cause 
shortness  of  breath,  an  asthmatic  attack,  palpitation,  angina  pectoris, 
or  cerebral  congestion  and  vertigo,  all  of  which  symptoms  are  alleviated 
by  belching  of  gas.  Flatulence  is  miich  more  characteristic  of  chronic 
enteritis  than  of  the  acute  type. 

Borborygmi  are  often  present.  Severe  pains  are  usually  absent, 
though  slight  colicky  pains  of  rather  brief  character  may  be  present. 
These  are  often  relieved  by  bowel  movement  or  by  the  expulsion  of  flatus. 

In  some  cases  the  general  health  is  not  impaired,  while  in  other  cases 
it  is  undermined.  General  nutrition  may  become  impaired,  especially 
if  the  small  intestine  is  also  involved.  In  the  latter  case  gastric  symptoms, 
such  as  anorexia  and  nausea,  and  occasionally  vomiting,  may  be  met 
with. 

The  patient  may  feel  weak,  disinclined  to  work,  be  irritable,  depressed, 
and  even  hypochondriac  or  melancholic.  There  may  be  loss  of  weight, 
anemia,  slow  pulse,  cold  extremities,  and  attacks  of  severe  headache. 
The  nervous  symptoms  are  due  in  part  to  depression  from  an  evidently 
chronic  and  persistent  disease,  and  in  a  large  degree  to  auto-intoxication. 

Physical  Signs. — The  abdomen  may  appear  distended,  especially  a 
couple  of  hours  after  eating,  with  some  tenderness  on  pressure.  In 
chronic  enteritis  the  colon  seems  to  be  more  usually  affected. 

Chronic  Catarrhal  Colitis. — There  may  be  chronic  catarrhal  colitis, 
with  tenderness  over  the  caput  coli  and  ascending  colon,  with  the  sensa- 
tion of  a  hard  mass  which  yields  to  the  examining  finger  on  pressure  (fecal 
accumulation),  or  this  part  may  be  tympanitic  and  give  the  splashing 
sound  from  gas  and  liquid.  The  same  may  be  true  over  the  descending 
colon,  sigmoid  flexure,  or  transverse  colon.  There  is  often  tenderness 
on  pressure  along  the  entire  colon.  Pain  is  felt  directly  under  the  point 
of  pressure,  or  occasionally  at  a  different  point  further  along  the  colon, 
due  to  the  passage  of  gas,  which  has  been  forced  along  by  local  pressure. 

In  thin  persons  peristaltic  movements  of  the  intestines  are  occasionally 
observed,  especially  after  palpation.  In  some  cases  there  are  no  special 
objective  symptoms. 

The  diagnostic  symptom  in  chronic  intestinal  catarrh  is  the  abnormal 
character  of  the  stool — the  presence  of  mucus. 

The  movements  are  irregular  and  the  consistence  of  the  stool  is  variable, 
but  the  mucus  is  diagnostic.     Diarrhea  is  not  a  constant  symptom. 

Types  of  Movements. — There  are  five  types  of  movements  which  occur 
in  chronic  enteritis: 

1.  In  one  set  of  cases  there  is  marked  constipation,  and  a  solid  move- 
ment occurs  only  once  every  two  or  three  days  and  at  times  only  after  a 
cathartic.  The  feces  are  usually  hard.  It  is  probably  due  to  a  diminished 
activity  of  the  automatic  nervous  mechanism  of  the  intestines  produced 
by  the  catarrh  (Nothnagel). 

2.  In  others,  constipation  and  diarrhea  alternate;  there  may  be  hard 
movements  for  several  days  and  these  succeeded  by  five  or  six  thin  or 
mushy  movements,  mixed  with  mucus,  and  accompanied  by  severe 
colicky  pains.     These,  in  turn,  will  be  followed  by  constipation,  and  so 


656  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

on.  In  some  instances  the  evacuations  will  be  fairly  normal  for  several 
days  and  then  diarrheal  movements  will  occur,  and  after  this  constipa- 
tion. Constipation  is  the  chief  feature  in  these  cases.  The  reflex  irri- 
tability of  the  nervous  apparatus,  however,  is  quite  good,  and  decomposi- 
tion of  the  stagnating  bowel  contents  eventually  causes  increased  peristalsis 
with  diarrhea. 

The  periods  of  constipation  or  diarrhea,  on  the  other  hand,  may  con- 
tinue for  a  long  time;  thus,  constipation  for  several  weeks  or  months,  and 
then  diarrhea  for  weeks  or  months.  Probably  in  the  latter  class  there  is 
an  acute  exacerbation  of  the  catarrh. 

3.  Rare  cases  occur  in  which  there  is  a  daily  evacuation  of  unformed 
and  mushy  feces. 

4.  Cases  in  which  for  months  the  patients  pass  several  diarrheal  stools 
each  day.  The  small  intestine  is  involved  as  well  as  the  large  bowel, 
as  there  is  a  bile-pigment  reaction,  as  a  rule,  or  there  are  yellow  frag- 
ments of  mucus,  or  epithelial  and  round  cells  tinged  with  bile.  The  food, 
on  account  of  the  catarrhal  process,  is  not  completely  digested  in  the 
small  intestine,  and  abnormal  products,  such  as  acids,  etc.,  are  produced, 
so  that  the  undigested  food  and  fermenting  material  give  rise  to  increased 
peristalsis. 

5.  In  addition,  there  are  some  in  which  the  nervous  element  is  a  factor 
combined  with  the  catarrh,  and  movements  occur  during  the  night  or 
early  in  the  morning.     F.  Delafield^  describes  this  type. 

Diagnosis. — The  presence  of  mucus  in  the  feces  is  characteristic.  The 
type  of  mucus  in  mucous  colic  (Enteritis  membranacea),  which  occurs  in 
large  amount,  and  the  symptoms  render  the  differential  diagnosis  com- 
paratively easy.  In  other  cases  the  presence  of  mucus  demonstrates  a 
true  catarrh.  In  habitual  constipation  there  may  be  a  thin  shellac-like 
covering  of  mucus  over  the  scybalae,  and  this  appearance  is  not  found  in 
chronic  enteritis.  With  chronic  catarrh  with  constipation,  the  quality 
of  the  dejecta  may  be  nearly  normal,  except  there  is  an  admixture  of  mucus. 
In  rare  cases  the  mucus  may  be  absent,  or  it  may  be  very  tough  and  adhere 
to  the  intestinal  wall,  or  the  scybalae  may  be  too  small  to  scrape  if  off. 
However,  on  most  occasions,  mucus  will  be  present,  and  if  there  is  doubt, 
washing  of  the  bowel  by  means  of  the  tube  and  funnel  will  eventually 
bring  it  away. 

Besides  the  presence  of  mucus  in  mucous  colic,  in  some  cases  of 
intestinal  dyspepsia  there  is  mucus  in  the  stools. 

Intestinal  Dyspepsia.  Chronic  Enteritis. 

Pure     mucus     alone.     Stools     gelatinous.  Mucus  with  epithelial  and   round  cells 

Mucus  microscopic  and  seldom  visible.  (diagnostic). 

Green  stools  with  acid  reaction;  bile-pigment 

gives  pronounced  reaction. 

No  fecal  odor.  Alkaline  stools.     Fecal  odor. 

The  quantity  of  mucus  varies  greatly;  in  most  cases  there  may  be 
only  a  small  or  moderate  amount. 

The  various  combinations  of  mucus  with  the  stool  and  the  localization 

^  Med.  Rec,  May  11,  1905. 


CHRONIC    CATARRH    OF    THE    INTESTINES  657 

of  the  catarrhal  process  have  been  described  under  Acute  Enteritis,  to 
which  I  refer  my  readers. 

We  may  have  therefore:  (i)  Chronic  catarrhal  enteritis  (alone), 
rare;  (2)  chronic  catarrhal  enterocolitis;  (3)  chronic  catarrh  of  various 
portions  or  of  the  entire  colon  or  of  the  rectum;  thus,  chronic  catarrh  of  the 
caput  coli,  of  the  ascending,  transverse,  or  descending  colon;  or  chronic 
catarrhal  sigmoiditis,  or  proctitis.     The  colon  is  most  frequently  involved. 

When  the  movements  are  watery  and  thin,  the  fecal  matter  is  a  light 
brownish  yellow  or  grayish  yellow,  and  may  contain  little  biliary  matter. 
Undigested  meat  or  starch  particles  can  often  be  seen  in  these  cases. 

Microscopically. — Though  nothing  may  be  discovered  macroscopically, 
we  may  find  with  the  microscope  undigested  meat-fibers,  starch  granules 
and  fat  droplets,  also  mucus  and  round  and  epithelial  cells,  at  times  yellow 
and  shrivelled  up.  They  indicate  catarrh  of  the  small  intestine.  Blood 
is  never  present  unless  due  to  ulcer,  or  hemorrhoids.  Pus  is  rarely  found 
and  only  as  isolated  cells. 

Dejecta  resembling  pus  diluted  with  water  (Blenorrhoea  intestinalis) 
shows  diphtheritic  inflammation  when  pus  is  seen  in  large  amount  under 
the  microscope.  Large  masses  of  epithelial  cells  in  various  degrees  of 
degeneration  are  present  in  chronic  catarrh.  They  are  responsible  for 
the  cloudiness  in  the  mucous  secretion. 

The  character  of  the  food  and  of  the  stool,  and  whether  there  is  con- 
stipation or  diarrhea,  determine  the  consistence  and  reaction  of  the 
feces  and  the  degree  of  fermentation.  As  a  rule,  alkaline  reaction  is 
present.  The  presence  of  fermentation  and  putrefaction  can  be  de- 
termined by  the  abdominal  tension,  flatus,  and  character  of  the  stool, 
which  may  be  fetid  and  present  a  foamy  surface. 

Fecal  material  may  be  placed  in  a  fermentation  tube  and  kept  at 
blood  temperature  for  several  hours,  and  the  degree  of  fermentation  or 
putrefaction  will  be  shown  by  the  quantity  of  gas  in  the  tube.  The 
method  is  described  under  Testing  the  Intestinal  Functions. 

The  presence  of  putrefaction  will  be  shown  by  indican  in  the  urine, 
and  the  Rosenbach  reaction  (Burgundy  red)  on  the  addition  of  nitric  acid 
and  boiling. 

A  chronic  catarrhal  enteritis  complicated  with  ulcers  will  show  marked 
diarrhea  with  pus  and  blood  in  the  stool.  If  the  ulcers  occur  in  the  small 
intestine  alone  and  there  is  no  diarrhea,  pus  and  blood  often  will  not  be 
present,  but  there  will  be  more  severe  pain,  more  marked  tenderness  on 
pressure,  and  the  clinical  symptoms  will  be  more  severe.  Occult  blood 
should  be  tested  for. 

The  diagnosis  of  the  atrophic  type  of  chronic  enteritis  is  extremely 
difficult.  Some  question  its  possibility.  There  will  be  a  previous  history 
of  intestinal  catarrh  of  long  standing.  Later  there  will  be  diarrhea,  no 
mucus,  with  gradual  loss  of  weight,  and  at  times  symptoms  of  pernicious 
anemia.  Tuberculosis  must  be  excluded.  This  condition  is  more  frequent 
in  the  young. 

Course. — The  course  of  chronic  intestinal  catarrh  is  usually  very 
tedious.     It  may  last  for  many  years.     There  may  be  periods  of  perfect 
health,  but  there  is  a  tendency  to  relapses  from  any  slight  indiscretion. 
42 


658  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Differential  Diagnosis. — The  method  of  localization  of  the  catarrh, 

as  previously  stated,  is  the  same  as  in  acute  enteritis. 

Irregular  bowel  action,  with  the  presence  of  mucus  in  the  stools  of  the 
character  described,  associated  with  abdominal  symptoms  of  discomfort, 
suggest  chronic  catarrh.  The  discharge  of  mucous  colic  is  characteristic, 
as  are  also  the  symptoms.  In  the  mucus  which  is  occasionally  found 
with  intestinal  dyspepsia  there  is  an  absence  of  epithelial  and  round  cells, 
and  the  stools  are  green  and  acid,  as  I  have  already  stated. 

In  habitual  constipation  there  is  an  absence  of  mucus  in  the  move- 
ments. With  marked  fecal  impaction  I  have  frequently  seen  a  small 
amount  of  mucus  in  the  feces  due  to  temporary  irritation.  After  re- 
moval of  the  impaction  and  subsequent  care  of  the  bowels  there  is  no 
further  appearance  of  mucus.  Impaction,  if  neglected  or  occurring  in 
frequent  attacks,  may  be  a  cause  of  local  intestinal  catarrh,  and,  as 
heretofore  noted,  occasionally  of  stercoral  ulcers. 

With  malignant  disease  of  the  intestines,  enteritis  is  often  associated, 
but  the  cachexia  is  marked  and  other  symptoms  of  the  neoplasm  are 
present.  With  intestinal  ulcers  there  are  marked  pains,  local  tenderness, 
and  pus  and  blood  in  the  stool.  With  enteroptosis  we  may  have  a  pro- 
lapse of  the  sigmoid,  fecal  accumulation,  and  chronic  catarrhal  sig- 
moiditis. In  every  case  of  chronic  intestinal  catarrh,  enteroptosis  should 
be  examined  for. 

Rectal  examination  should  be  made  in  every  case  of  chronic  intestinal 
catarrh,  as  the  focus  occasionally  starts  from  the  rectum  and  progresses 
up  the  bowel  as,  for  example,  from  an  ulcer.  On  account  of  its  importance 
I  shall  devote  later  a  brief  section  to  Proctitis. 

A  uterine  fibroid  may  block  the  bowel,  acting  as  a  ball-valve,  and, 
from  fecal  accumulation  above  this  point,  a  marked  catarrh  of  the  mucous 
membrane  may  result. 

Chronic  appendicitis  may  result  from  a  chronic  intestinal  catarrh, 
while  in  some  cases  a  chronic  appendicitis  may  act  as  a  focus  of  irritation 
for  a  localized  chronic  catarrh  in  the  cecum.  Removal  of  the  appendix 
is  curative  in  the  last  type.  In  certain  diseases  of  the  stomach  there  may 
be  constipation  or  diarrhea,  but  the  absence  of  mucus  in  the  stools  and 
examination  of  the  gastric  contents  will  settle  the  question. 

In  chronic  enteritis  of  the  small  intestine  alone  there  are  usually  gastric 
symptoms,  constipation,  yellow  tinged  mucus  in  the  stools,  generally 
microscopic  and  well  mixed  with  the  feces,  and  the  biliary  salts  reaction. 

With  chronic  catarrhal  colitis  there  is  usually  more  constipation^  and 
more  or  less  mucus  of  a  grayish  tinge,  either  covering,  or  on  the  surface 
of  the  feces  or  in  small  strings.  Pure  mucus  may  at  times  be  voided  at 
the  end  of  defecation  if  the  lower  bowel  is  affected.  Palpation  is  of  value 
in  locating  the  position  of  the  chronic  colitis,  as  the  affected  area  is  apt 
to  be  sensitive  to  pressure. 

Chronic  diarrhea  is  prominent  in  cases  in  which  both  the  small  and 
large  intestines  are  involved,  and  the  mucus  may  be  yellow  in  color  and 
considerable  undigested  food  is  often  present. 

Prognosis. — This   depends   on   the   severity   of   the   symptoms,   the 
duration  of  the  disease,  and  the  physical  condition  of  the  patient. 
'Diarrhea,  or  alternating  constipation  and  diarrhea  may  occur, however. 


CHRONIC    CATAKRH    OF    THE    INTESTINES  659 

In  the  very  young,  very  old,  or  those  weakened  by  some  other  disease, 
such  as  endocarditis  or  tuberculosis,  severe  types  of  chronic  catarrh  may 
be  accessory  in  producing  a  fatal  result. 

As  a  rule,  the  prognosis  as  to  life  is  favorable,  but  in  tne  severer  cases 
of  long  standing  it  is  not  so  favorable  as  to  perfect  cure. 

The  cases  have  a  tendency  to  relapse,  especially  after  indiscretions, 
though  they  may  continue  for  a  considerable  time  with  comparative 
comfort.  The  milder  •  cases  of  not  long  standing  may  recover  under 
appropriate  treatment. 

Treatment. — The  cause  of  the  chronic  catarrh  should  be  carefully 
sought  out  and  corrected.  If,  for  example,  endocarditis  with  resulting 
circulatory  disturbances  (which  are  a  predisposing  factor)  be  present, 
this  should  receive  treatment.  The  Nauheim  bath,  even  though  taken 
at  home  by  means  of  the  Triton  salts,  would  be  of  value  in  such  cases. 
If  enteroptosis  is  present,  such  as  in  the  case  I  have  described,  where 
there  was  marked  prolapse  of  the  sigmoid,  fecal  accumulation,  and  local 
chronic  catarrh,  treatment  by  abdominal  support  (Rose's  belt)  and  in- 
creasing the  nutrition  by  the  methods  described  under  Gastroptosis 
would  be  indicated,  in  addition  to  the  general  treatment  for  chronic 
catarrh.  I  have  seen  one  obstinate  case  cured  by  S.  Gant  by  drawing  up 
and  suturing  the  sigmoid  to  the  abdominal  muscles.  Angulations  of 
the  sigmoid  should  be  corrected.  If  worms  are  present,  they  should  be 
removed. 

These  remarks  will  sufficiently  illustrate  the  necessity  for  investigation 
of  the  cause  of  the  catarrh.  Hygienic  and  dietetic  measures  are  of  great 
importance. 

The  patient  should  regulate  his  life  carefully,  not  overwork  nor  be 
under  too  great  business  strain,  eat  slowly  and  at  regular  hours,  and  live 
in  the  open  air  as  much  as  possible.  In  the  constipated  cases  consider- 
able exercise  is  of  value.  When  the  diarrhea  is  marked  the  patient  should 
keep  quiet  during  its  active  stage,  and  in  some  cases  remain  in  bed  until 
it  has  passed.  Nervous  disturbances  should  be  avoided.  The  patient 
should  exercise  care  not  to  wet  the  feet  or  undergo  exposure  to  cold,  and 
should  be  properly  protected  in  rainy  weather.  A  flannel  band  about  the 
abdomen  is  of  value.     Change  of  scene  and  climate  are  often  serviceable. 

Diet. — The  patient  should  eat  at  regular  hours,  slowly,  and  masticate 
thoroughly.  It  is  preferable  to  give  small  meals  more  frequently  than 
three  large  meals,  and  sufficient  nourishment  should  be  administered  so 
that  there  is  an  increase  in  weight. 

Fried  foods,  hot  breads,  rich  pastries,  desserts,  and  indigestible  sub- 
stances should  be  avoided.  Though  some  allow  the  very  moderate  use 
of  light  wines,  and  occasionally  beer  or  ale,  in  constif)ated  cases,  and  the 
use  of  claret  in  diarrhea,  in  my  own  experience,  I  find  that  patients  with 
catarrhal  conditions  of  the  gastro-intestinal  tract  do  much  better  by 
eliminating  alcoholic  beverages  altogether. 

The  character  of  the  diet  is  dependent  upon  whether  diarrhea  or 
constipation  is  present.  • 

In  diarrheal  cases,  if  the  type  be  severe,  milk  and  lime-water  equal 
parts,  or  boiled  milk,  or  milk  and  barley-water,  or  rice-water  in  combina- 


66o  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

tion,  often  are  efficacious,  though  some  patients  have  an  idiosyncrasy 
to  milk.     Rest  in  bed  for  a  brief  period  may  be  necessary. 

Koumiss,  matzoon,  bacillac,  fermillac  or  lactone-buttermilk  are  often 
useful  in  such  cases,  though  with  some  these  preparations  are  objection- 
able, increasing  the  diarrhea,  also  raw  eggs  beaten  in  milk,  may  be  of 
value. 

In  milder  cases  of  diarrhea  the  diet  may  be  more  liberal.  Carbonated 
waters,  lemonade,  fruits,  salads,  acids,  cabbage,  cauliflower,  rye  bread, 
brown  bread,  ice-cream,  pastries,  oatmeal,  green  vegetables,  corn  and 
beans,  turnips,  carrots,  beets,  radishes,  celery,  and  lobster  should  be 
avoided.  Mashed  and  baked  potatoes,  rice,  sago,  macaroni,  bread  well 
baked  and  toasted,  with  a  moderate  amount  of  butter,  cream,  soups, 
bouillon,  soft-boiled  or  scrambled  eggs,  sweet-breads,  calves'  brains, 
chicken,  lamb  chops,  lean  fish,  cocoa,  tea  and  milk,  or  matzoon  Cwith 
some)  can  be  given. 

The  drinks  should  not  be  too  hot  or  too  colds,  and  an  excess  of  liquid 
should  be  avoided. 

In  constipated  cases  the  diet  must  be  more  liberal.  In  addition  to 
the  food  mentioned  above,  fruits,  such  as  oranges,  ripe  pears,  grapes, 
green  vegetables,  such  as  spinach,  peas,  lettuce,  cauliflower,  plenty  of 
butter,  cream,  and  fluids  are  of  service,  whole  wheat  crackers  are  useful. 

Cabbage,  cucumbers,  brown  bread,  sausages,  lobster,  and  mayonnaise 
dressing,  should  be  avoided  in  these  cases  also.  Bran  biscuits  are  of 
value. 

The  urine  findings  should  modify  the  diet — if  indicanuria,  less  meat 
or  none  for  a  time;  if  intestinal  fermentation,  less  vegetables;  if  nephritis, 
an  appropriate  diet. 

Massage. — In  cases  characterized  by  chronic  constipation,  gentle  massage 
over  the  course  of  the  colon  or  the  use  of  a  light  cannon-ball  is  indicated. 
No  pressure  should  be  exerted  on  the  ball,  but  it  should  be  rolled  along 
the  colon  for  five  minutes  morning  and  night.  Light  vibratory  massage 
is  of  value  under  similar  conditions. 

Hydrotherapy. — Warm  salt  baths  at  98°  to  ioo°F.,  or  Nauheim  baths 
(artificial),  eight  to  ten  minutes  every  other  day  for  two  or  three  weeks, 
or  pine-needle  baths,  bran  baths,  or  mud  baths  may  be  of  some  service 
in  some  diarrheal  cases.  Cold  baths  should  be  avoided  in  diarrhea.  A 
Priessnitz  wet  pack  over  the  abdomen  is  of  value  when  applied  on  retiring. 

Cold  showers  and  cold  sponges  are  of  service  in  nervous  cases.  Cold 
sitz-baths  and  cold  douches  over  the  abdomen  are  of  use  in  constipated 
cases,  but  should  be  preferably  carried  out  at  some  sanatorium.  I  have 
rarely  found  the  latter  methods  necessary,  but  use  the  artificial  Nauheim, 
pine-needle,  or  bran-  baths,  also  the  cold  compress  to  a  considerable 
extent. 

Mineral  Waters. — A  methodic  course  of  drinking  certain  alkaline  or 
saline  mineral  waters  has  proved  beneficial  in  many  cases.  When  taken 
at  the  springs,  the  patient  is  obliged  to  follow  a  rational  method  of  life 
and  diet  and  is  free  from  worry,  and  thus  receives  additional  benefit. 
Carlsbad  is  especially  valuable  when  there  is  a  tendency  to  diarrhea,  and 
Vichy  is  next. 


CHRONIC    CATARRH    OF    THE    INTESTINES  66 1 

In  cases  of  marked  constipation,  Marienbad  is  of  service,  and  also  the 
Hawthorne  and  Congress  Springs  at  Saratoga.  Virginia  Hot  Springs  are 
also  to  be  recommended.  Where  neither  diarrhea  nor  constipation  are 
prominent,  Kissengen  or  Homberg;  with  constipation  and  anemia, 
Franzensbad  and  Elster. 

Carlsbad  water  should  be  taken  in  small  quantities,  a  wineglassful 
twice  a  day,  or  small  amounts  of  the  imported  salts,  30  to  60  grains 
(2.0  to  4.0),  three  to  five  times  a  day.  It  is  preferable  to  begin  with 
small  doses.  Some  do  badly  with  this  method.  If  the  diarrhea  increases 
so  that  the  patient  begins  to  lose  weight,  the  treatment  should  be  dis- 
continued at  once. 

Medication. — The  method  of  internal  medication  depends  upon 
whether  constipation  or  diarrhea  is  the  existing  condition.  As  a  prelimi- 
nary it  is  always  wise  to  begin  treatment  with  a  thorough  cleansing  of 
the  intestines  by  a  single  dose  of  castor  oil,  i}i  ounces  (45.0),  or  a  good 
dose  of  Carlsbad  salts  or  magnesium  sulphate. 

If  there  be  marked  fecal  accumulation,  it  is  better  first  to  employ 
enteroclysis  or  enemata,  to  remove  the  impaction,  and  then  follow  with 
the  single  cathartic. 

In  constipated  cases,  fruits,  buttermilk,  cold  water  (glass)  on  rising, 
stewed  fruits,  and  a  regular  hour  for  attempted  stool  are  all  rational. 

An  enema,  olive  oil,  4  ounces  (125.0),  increasing  to  i  pint  (500  c.c.) 
or  more,  given  slowly  by  a  long  tube  on  retiring,  and  to  be  retained,  is  an 
excellent  procedure.  It  may  be  necessary  to  employ  soapsuds  enema 
(never  over  i  quart)  or  normal  salt  solution.  Russian  or  American 
mineral  oil  at  night  may  be  required.  Rhubarb  pills,  fluidextract  of 
cascara  in  i-dram  (4.0)  doses,  or  the  same  quantity  of  aromatic  fluid- 
extract  of  cascara,  regulin,  or  podophyllin  pills  are  of  service.  Carlsbad 
water  has  been  given  by  enema. 

Small  doses  of  castor  oil  or  olive  oil  combined  with  salol  are  of  considerable 
value  in  all  cases.     Thus: 

Salol,  ^-grain  (0.3)  tablet;  with  it  give  castor  oil,  10  minims  (0.59), 
in  a  soft  gelatin  capsule  coated  with  shellac,  four  times  a  day;  or  olive  oil 
can  be  substituted.  The  gelatin  capsules  containing  salol  and  castor  oil 
can  be  secured  already  prepared. 

In  the  constipated  cases  larger  doses  of  olive  oil  by  mouth,  i  to  4 
ounces  (30.0-125.0)  t.i.d.,  are  of  service. 

The  oil  preparations  seem  to  have  an  excellent  effect  on  the  mucous 
membrane.    Lead  and  zinc  preparations  I  do  not  employ. 

Nitrate  of  silver  is  sometimes  of  service.  It  can  be  given  in  aqueous 
solution,  each  i  dram  containing  }i  to  }4  grain  (0.011-0.016),  being  kept 
in  a  dark  bottle,  or  the  same  dosage  in  an  enteric  coating. 

The  following  pill,  }^  grain  (0.008),  of  silver  nitrate  is  excellent: 

I^.  Argenti  nitratis gr.  v  (0.3) 

Resin  turpentine  1  =.    ir-/-      \ 

Liq.potass.  / *^   3 J  (4.0) 

Pulv.  licorice q.  s. — M. 

Div.  in  pil.  No.  xl. 
Sig. — One  pill  t.i.d. 


662  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Bismuth  salicylate,  5  to  10  grains  (0.3-0.6)  t.i.d.,  is  of  some  value, 
but  a  movement  should  be  secured  every  day  if  it  is  given  in  the  constipated 
cases. 

The  bismuth  and  tannin  preparations  are  of  special  value  in  the 
diarrheal  cases,  the  dosage  being  dependent  on  their  severity.  The 
movements  should  be  reduced  to  one  or,  at  the  most,  two  a  day.  Opiates 
I  always  avoid,  if  possible. 

Bismuth  subnitrate,  10  to  20  grains  (0.6—1.3)  three  or  four  times  a 
day  or  more,  alone  or  combined  with  chalk  mixture. 

Bismuth  salicylate,  5  to  10  grains  (0.3-0.6)  t.i.d.,  combined  with  sub- 
nitrate  bismuth;  or  bismuth  subcarbonate,  10  to  20  grains  (0.6-1.3) 
t.i.d.;  or  bismuth  subgallate,  5  to  10  grains  (0.3-0.6)  t.i.d. 

Tannigen,  tannalbin,  or  tannopin,  5  to  15  grains  (0.3-1.0)  t.i.d. 

Beta-naphthol-bismuth,  5  grains  (0.3)  three  or  four  times  a  day,  if 
there  is  fermentation.  For  some  of  the  combinations  with  kino,  catechu, 
etc.,  I  refer  to  treatment  of  Acute  Enteritis. 

Belladonna  can  be  used  for  pains,  but  codein  and  morphin  rarely 
should  be  employed. 

Local  Treatment. — This  is  of  great  importance,  especially  when  the 
large  intestine  is  involved,  which  is  usual.  This  method  may  be  em- 
ployed by  an  enema  of  i  pint  (500  c.c.)  to  i  or  even  2  quarts  (liters)  of 
the  solution,  preferably  employing  several  quarts  (liters),  with  the  re- 
current tube  or  two  tubes.  If  possible  I  use  my  own  rectal  irrigator  of 
hard  rubber,  or,  if  the  rectum  is  sensitive,  the  soft-rubber  tube  or  two 
catheters. 

Normal  saline  solution — i  dram  (4.0)  salt  to  i  pint  (500  c.c.)  water 
— at  105°  to  iio°F.  is  excellent  if  there  is  much  pain.  Oil  of  peppermint 
(10  drops)  can  be  added  to  this.  Flaxseed  tea  at  the  same  temperature 
is  useful.  Slippery  elm  solution  and  gum-arabic  solution  are  excellent 
soothing  applications. 

Listerin,  glycothymolin,  borolyptol,  and  boric  acid,  i  to  2  drams 
(4.0-8.0)  to  the  quart,  are  of  service. 

Tannin,  gr.  10  to  20  (0.6-1.3)  to  the  quart  (Uter);  zinc  sulphocarbolate, 
10  to  15  grains  (0.6-1.0);  or  borax,  i  dram  (4.0)  to  the  quart,  are  good 
astringents;  salicylic  acid,  15  grains  (i.o)  to  the  quart  (liter);  irrigation 
once  a  day  or  every  other  day  is  of  value. 

I  often  employ  flaxseed  tea  or  gum-arabic  one  day,  and  one  of  the 
mild  antiseptics  or  astringents  the  following  day. 

In  obstinate  cases,  nitrate  of  silver  solution,  10  to  20  grains  (0.6- 
1.3)  to  a  quart  (liter),  given  once  or  twice  a  week,  is  a  valuable  adjunct. 
If  the  patient  complains  of  pain,  a  subsequent  injection  of  normal  saline 
solution  is  of  service. 

The  bowels  should  be  thoroughly  emptied,  preferably  an  enema  given 
an  hour  or  two  before  local  treatment. 

Protargol  or  argyrol  (1:1000  or  1:1500)  is  of  service  in  place  of 
the  silver  nitrate. 

Rectal  inflation  with  oxygen  has  been  advocated  by  Gross^  particularly 
when  fermentation  and  putrefaction  are  associated  with  the  catarrh. 
^  Med.  Rec,  Nov.  30,  191 2. 


PROCTITIS  663 

Surgery. — In  cases  with  evident  ulceration,  if  no  benefit  results  from 
medical  treatment  conscientiously  applied  for  a  year,  I  would  advocate 
appendicostomy  or  cecostomy  with  subsequent  intestinal  irrigations. 
In  catarrh  without  ulcers,  I  do  not  believe  operation  is  indicated. 

PROCTITIS 

The  rectum  is  very  liable  to  bacterial  infection,  both  from  within  and 
without,  through  the  anal  opening,  so  that  ulcerations  and  periproctitis 
may  occur.  I  will  briefly  refer  to  this  disease,  merely  to  serve  as  an 
index  to  the  practitioner. 

Etiology. — As  this  condition  is  often  a  part  of  chronic  enteritis,  the 
etiologic  factors  may  be  identical.  Local  conditions  may  also  produce 
it;  thus,  traumatism,  as  by  a  syringe-tip;  sodomy;  impacted  feces;  worms; 
foreign  bodies  introduced  through  the  rectum  or  lodged  there  during  their 
passage  from  above,  such  as  fish-bones,  pins,  etc.,  hemorrhoids,  polypi; 
prolapse,  intussusception;  tumors;  pressure  from  other  organs;  displace- 
ment of  the  uterus;  stone  in  the  bladder;  inflammation  of  adjacent  organs, 
such  as  uterus,  tubes,  prostate,  or  seminal  vesicles.  Sitting  on  cold 
stones  or  wet  seats  may  be  a  cause.  Idiosyncrasies  to  certain  foods  seem 
to  be  a  factor. 

Proctitis  is  classified  as  follows: 

1.  Acute  simple  catarrhal  proctitis. 

2.  Chronic  proctitis:  Atrophic  form;  hypertrophic  form. 

3.  Specific  forms:  Gonorrheal,  dysenteric,  diphtheritic,  erysipelatous, 
and  syphilitic  proctitis. 

Pathology. — With  simple  catarrh  there  is  no  pus,  except  possibly 
a  minute  amount.     With  ulceration  there  are  pus  and  blood. 

The  acute  and  chronic  types  of  intestinal  catarrh  have  already  been 
described.  It  is  preferable  to  examine  pus  (if  such  is  present)  for  gonor- 
rhea, especially  if  there  be  a  gonorrheal  vaginitis,  and  it  may  even  pass 
by  extension  from  Bartholin's  glands. 

Erysipelas  may  extend  from  without.  Pseudomembranes  occur  with 
the  diphtheritic  type.  Amebae,  or  the  bacilli  dysenteriae,  are  found  with 
the  dysenteric  type.  We  may  have  the  primary  chancre  of  syphilis  in 
the  rectum,  in  which  case  relaxation  of  the  sphincter  will  also  be  noted, 
or  there  may  be  secondary  ulceration  and  catarrh.  The  test  for  Wasser- 
mann's  or  Noguchi's  reaction  should  be  made  if  syphilis  is  suspected. 
Actinomycosis  may  rarely  occur. 

Primary  rectal  infection  from  the  larvae  of  flies  (myiasis)  has  been  re- 
ported by  Nicholson.^  The  patients  all  suffered  from  hemorrhoids  with 
rectal  prolapse  and  exposure  of  the  rectal  mucosa  to  fly  infection  thus 
resulted.  Protection  of  the  prolapsed  mucosa  prevented  subsequent 
infection. 

Symptoms. — They  have  been  described.  They  are:  Marked  strain- 
ing and  tenesmus;  passage  of  mucus  with  the  stool,  or  mucus  alone  with 
pus  and  blood  if  ulceration  is  present;  frequent  micturition;  throbbing  heat 
and  weight  in  the  rectum.  Constipation  at  first,  later  diarrhea;  heavy 
^  Jour.  Amer.  Med.  .\ssoc.,  May  21,   1910. 


664  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

and  aching  pain  in  the  rectum  and  down  the  limbs;  often  pruritus  and 
prolapse  of  the  rectal  mucous  membrane  or  hemorrhoids;  temperature 
in  the  acute  cases;  coated  tongue;  abscesses  of  the  rectum  may  develop. 

The  chronic  cases  present  less  severe  symptoms,  and  no  temperature. 

Thus,  there  may  be  pain  referred  to  the  rectum,  or  a  feeling  of  weight 
and  pressure  within  the  pelvis  or  over  the  sacrum.  There  may  be  reflex 
pain  down  the  left  leg,  simulating  sciatica,  dysmenorrhea,  dysuria  with 
no  discoverable  lesions  in  the  genito-urinary  tract,  swelling  of  the  left  leg, 
anemia,  and  loss  of  weight.  In  young  children  there  are  often  picking 
the  nose,  scratching  the  anus,  straining  and  protrusion  at  stool,  as 
symptoms.     Mucus,  pus,  or  blood  may  be  found  in  the  feces. 

Digital  examination  is  painful  on  account  of  spasm,  and  the  rectum 
^vill  be  found  to  be  very  sensitive  and  hot  to  the  feel.  If  the  inflammation 
extend  deeper  into  the  tissues,  it  will  feel  hard  and  rigid. 

By  speculum  examination  it  will  be  seen  to  be  a  deep  red,  with  hemor- 
rhages and  erosions.  Often  the  condition  is  so  painful  that  it  is  not  ad- 
visable to  use  a  speculum  at  first.  The  chronic  cases  run  a  less  severe 
course.     Complications :     Periproctitis  or  ischiorectal  abscess  may  occur. 

Treatment. — Recurrent  rectal  irrigation  with  hot  normal  saline  solu- 
tion at  iio°F.,  or  in  other  cases  with  cold  saline  solution  at  50°  to  7o°F., 
with  the  patient  in  the  Sims  posture  for  fifteen  minutes'  duration,  is  of 
value,  once  or  twice  a  day,  to  relieve  inflammation.  Flaxseed-tea  irriga- 
tion is  also  useful,  or  the  other  antiseptics  described  under  Chronic 
Enteritis. 

Injection  of  hydrastis,  i  to  2  per  cent.,  or  aqueous  fluidextract  of 
krameria  (J.  P.  Tuttle),  5  to  20  per  cent.,  several  quarts,  are  of  service  in 
some  cases. 

Carbolic  acid  solutions  should  never  he  employed. 

In  the  acute  conditions  I  do  not  care  to  employ  nitrate  of  silver  at 
first,  though  later  i  :  2000  every  day  or  two  is  of  value. 

Argyrol  or  protargol  (i  :  500  or  i  :  1000)  is  less  irritating.  Tuttle 
suggests  the  lise  of  the  following  by  injection  to  quiet  irritation  after  local 
treatment. 

I^.     Flaxseed  tea 5j  (30.0); 

Opium gr.  ss  to  j  (0.32-0.065) ; 

Aqueous  fl.  ext.  krameria ir^xxx  (1.77). — M. 

A  suppository  of  opium  and  iodoform  may  be  substituted. 

If  there  is  marked  purulent  inflammation,  then  twice  daily  irrigate 
with: 

Peroxid  of  hydrogen  8  to  10  per  cent.,  or  i  :  1000  acetozone  or  alpha- 
zone,  or  even  i  :  10,000  bichlorid  of  mercury  once  in  twenty-four  hours. 
The  latter  should  be  used  by  the  recurrent  method  only. 

The  bowel  should  be  irrigated  well  with  saline  solution  after  each 
movement  and  medicated  solutions  used  once  or  twice  a  day. 

Injections  of  starch  and  laudanum  should  only  be  used  once  or  twice 
a  day  in  severe  cases  to  relieve  irritability. 

After  the  acute  stage  has  passed  S.  Gant  recommends  spraying  the 
rectum  with  permanganate  of  potassium  (i  :  3000),  or  with  zinc  sulphate, 
copper  sulphate,  or  nitrate  of  silver,  i  per  cent. 


PHLEGMONOUS    (pURULENT)    ENTERITIS  665 

In  chronic  cases  irrigation  with  nitrate  of  silver  (i  :  2000  to  i  14000) 
is  of  value,  every  two  or  three  days,  or  with  protargol  or  argyrol  1-1500 
to  i-iooo. 

I  have  seen  an  excellent  result  in  a  severe  chronic  case  from  the  injec- 
tion of  the  aqueous  fluidextract  of  krameria,  suggested  by  J.  P.  Tuttle. 
His  formula  is  as  follows: 

Macerate  i  pound  of  bark  of  krameria  in  a  long  percolating  tube 
twenty-four  hours.  After  this  a  mixture  of  glycerin  (20  per  cent.)  and 
water  (80  per'  cent.)  is  allowed  to  percolate  through  it.  The  percolate 
should  be  constantly  stirred  and  refiltered  through  the  bark  a  second 
time. 

The  filtrate  is  then  evaporated  down  to  i  pound,  thus  obtaining  an 
aqueous  fluidextract  containing  gram  for  gram  all  the  therapeutic  proper- 
ties of  the  bark.  The  preparation  should  be  kept  in  a  dark  place  and  not 
exposed  to  air. 

A  10  to  20  per  cent,  solution  of  this  can  be  used  for  irrigation,  or  a  local 
application  of  it  pure. 

The  diet  and  internal  medication  should  be  the  same  as  described 
under  Chronic  Enteritis.  Syphilis,  if  present,  should  be  treated  by 
"606,"  neosalvarsan  or  mercury  and  the  iodids. 

Warm  sitz-baths  aid  in  relieving  pain. 

PHLEGMONOUS  (PURULENT)  ENTERITIS 

This  disease,  a  purulent  inflammation  of  the  submucous  tissue  of  the 
intestines,  is  rare  as  a  primary  process.  It  is  probably  due  to  str^tococcic 
infection,  the  jejunum  being  most  frequently  involved. 

Several  epidemics  have  been  reported  among  children  one  at  the 
Sheltering  Arms  in  19 10  and  another  in  1913.  The  stools  were  very 
offensive  and  complications  such  as  septic  pneumonia,  otitis  and  menin- 
gitis occurred.  Bartley  ^  reports  six  deaths  out  of  25  cases.  This  condition 
is  evidently  less  fatal  in  children  than  in  adults.  Peritonitis  is  often 
present,  but  the  purulent  enteritis  cannot  usually  be  diagnosed  as  the 
cause,  in  my  opinion  until  after  operation.  The  writer  has  seen  one  case 
which  was  secondary  to  intestinal  ulcers,  where  the  bacteria  (streptococci) 
appeared  in  great  quantities  in  the  stool.  Autogenous  vaccines  and  local 
irrigation  (intestinal)  were  advised.  Phlegmonous  enteritis  may  be 
secondary  to  intestinal  ulceration,  to  intussusception,  or  strangulated 
hernia.  Maragliano  has  reported  septic  infection  of  the  ileum  probably 
by  the  colon  bacillus,  with  hemorrhage,  ulceration,  and  peritonitis.  The 
large  intestine  may  be  involved  and  Dowd^  reports  such  a  case,  with 
recovery  after  resection  and  enter  oenter  ostomy.  The  staphylococcus 
pyogenes  aureus,  Bacillus  proteus,  etc.,  may  also  be  responsible  for 
phlegmonous  enteritis.  Delafield  and  Prudden^  refer  to  a  fatal  necrotic 
colitis  septic  in  character  as  does  Ziegler*  and  gangrenous  enteritis  with 
acute  phlegmonous  cholecystitis"  has  been  reported. 

1  N.  Y.  State  Journal  of  Medicine,  Dec,  1914. 

2  N.  Y.  Surg.  Soc,  Mar.  27,  191 2. 

'  Handbook  of  Path.  Anat.  and  Histol.,  9th  Ed.,  p.  681. 
*  Text-book  of  Spec.  Pathol.  Anatomy.,  loth  Ed.,  p.  662. 
'  Med.  Rec,  Dec.  13,  1913. 


CHAPTER  XXVI 
DYSENTERY 

Dysentery  is  defined  as  an  infectious  disease  characterized  by  specific 
ulcerations  of  the  large  intestine.  In  typic  acute  cases  it  gives  rise  to 
bloody  mucus  or  mucopurulent  dejections,  accompanied  by  tenesmus 
and  general  symptoms. 

Dysentery  was  known  to  .the  ancient  world,  being  first  described 
accurately  by  Hippocrates  430  b.  c,  and  later  by  Celsus,  Aretaeus,  and 
Galen. 

In  1506  the  first  records  of  postmortem  examinations  of  dysenteric 
subjects  were  published  in  the  posthumous  work  of  Antonio  Benevieni. 
Following  these  came  many  writers,  among  whom  I  shall  mention  a  few 
of  the  most  prominent  of  recent  years:  Cruveilhier,  Virchow,  Wood- 
ward, Lambl,  Loesch,  Kartulis,  Quincke,  Roos,  Musser,  Osier,  Stengel, 
Stockton,  Harris,  Councilman,  Lafleur,  Ogata,  Shiga,  Russell,  Flexner, 
His,  Barker,  Duval,  Bassett,  Vedder,  Musgrave,  Strong,  Craig, 
and  Thomas. 

It  has  been  demonstrated  that  the  disease  is  due  to  infections  of  a 
specific  type — either  to  the  amoeba  dysenterise,  or  to  the  Bacillus  dysenteriae 
(Shiga)  or  one  of  its  strains.  The  disease  is  transmitted  in  the  same 
way  as  is  typhoid  fever.  It  sometimes  assumes  a  diphtheritic  type,  in 
which  case  other  bacteria  are  undoubtedly  associated. 

In  the  ileocolitis  of  infants,  dysenteric  bacilli  of  various  strains  have 
been  discovered,  and  some  of  these  cases,  both  clinically  and  pathologically , 
present  the  appearance  of  an  acute  catarrh. 

The  so-called  acute  catarrhal  dysentery,  the  sporadic  form,  I  believe, 
is  undoubtedly  due  to  the  Bacillus  dysenteriae  or  one  of  its  strains. 

DEPHTHERITIC  DYSENTERY 

Diphtheritic  dysentery  (or,  more  strictly  speaking,  pseudodiphtheritic,  as 
Klebs-Loffler  bacillus  is  not  present)  has  been  shown  in  many  cases  to  be 
due  to  the  Bacillus  dysenteriae.  Utidouhtedly  mixed  infections  with  other 
bacteria  are  found  in  this  type. 

They  may  be  found  in  combination  with  amebic  dysentery,  and,  in 
addition,  in  some  of  the  amebic  liver  abscesses  numerous  other  bacteria 
are  present,  which  demonstrate  mixed  infection  from  other  sources. 

Secondary  diphtheritic  dysentery  is  a  common  terminal  event  in  many 
acute  and  chronic  diseases;  and  Vedder  and  Duval  have  demonstrated 
that  the  Bacillus  dysenteriae  is  present  in  these  cases. 

Diphtheritic  dysentery  in  which  the  diplococcus  pneumoniae  has  been 
isolated  has  been  several  times  reported.  In  addition,  mercurial  poison- 
ing or  uremia  may  have  this  lesion  associated.     It  is  evident,  therefore, 

666 


DYSENTERY  667 

that  other  bacteria,  either  present  in,  or  entering  the  intestinal  tract  under 
favorable  conditions,  may  produce  this  lesion. 

PREDISPOSING  CAUSES  AND  CLIMATIC  LOCATION 

Many  causes  were  formerly  given  for  the  production  of  dysentery, 
but  we  may  say  that,  they  only  predispose  to  infection,  on  account  of 
weakening  the  organism,  producing  intestinal  disturbances.  In  the  case 
of  overcrowding  in  asylums  and  camps,  there  is  a  tendency  to  unsanitary 
conditions.  By  inattention  to  the  proper  relation  of  the  latrines  to  the 
water-supply,  for  example,  there  may  result  a  severe  epidemic. 

Dysentery  is  found  in  all  parts  of  the  world,  but  is  endemic  and  often 
epidemic.  It  is  most  common  in  warm  climates,  such  as  the  southern 
United  States,  Cuba,  the  Philippines,  southern  coast-line  of  Asia,  Africa, 
Egypt,  Mexico,  Central  and  South  America.  It  has  been  met  with  in 
cold  climes,  as  in  North  Russia  and  Greenland;  is  sporadic  in  all  parts  of 
the  United  States  and  occasionally  epidemic.  Severe  epidemics  have 
occurred  in  the  New  England  States. 

During  the  Civil  War,  Woodward  collected  259,071  cases  of  acute 
dysentery  and  28,451  of  chronic  dysentery  in  the  Federal  service. 

During  the  recent  Spanish-American  War  the  mortality  from  dysentery 
and  typhoid  was  far  in  excess  of  that  from  battle;  and  in  the  African  War 
the  English  troops  suffered  severely.  In  the  Russo-Japanese  War  the 
deaths  in  the  Japanese  army  from  dysentery  and  typhoid  were  infini- 
tesimal in  number,  demonstrating  that  by  intelligent  care  of  the  water- 
supply  and  proper  sanitation  epidemics  of  dysentery  can  be  absolutely 
stamped  out. 

Dampness,  overcrowding,  and  imperfect  ventilation  vitiate  the  system, 
and  so  predispose  to  subsequent  infection.  With  overcrowding  and 
necessarily  insufficient  and  improper  attention  to  sanitary  conditions, 
infection  from  the  dejecta  can  readily  occur,  if  a  sporadic  case  develop. 

Heat  and  moisture  predispose  to  intestinal  disturbances,  and  readily 
cause  changes  in  fresh  fruits  or  canned  material,  if  improperly  cared  for, 
which  in  turn  produce  diarrheal  disturbances,  and  cause  susceptibility 
to  infection.  Sudden  alternations  from  heat  to  cold  produce  the  same 
result.     Errors  in  diet  are  predisposing  causes. 

No  race  or  age  is  exempt  from  dysentery,  and  a  person  going  from  his 
native  to  a  warm  climate — with  the  sudden  change  in  food  and  mode  of 
life  incident  thereto — is  probably  more  susceptible. 

Dysentery  is  more  fatal  among  the  poor  and  ill-nourished  than  among 
the  rich,  though  the  latter  are  not  exempt.  It  is  probably  more  prevalent 
in  epidemic  and  endemic  form  in  small  country  towns,  villages,  and 
farms,  where  one  so  frequently  sees  the  well  in  close  proximity  to  the 
privy,  a  stagnant  pool,  or  the  family  cow-yard. 

Dysentery  may  be  endemic,  the  so-called  tropical  dysentery;  epidemic 
or  diphtheritic;  and  sporadic  (the  acute  catarrhal  dysentery). 

It  is  classified  as  follows: 

I.  Amebic  'dysentery,  in  which  there  is  at  times  a  mixed  infection 
(diphtheritic  process). 


668  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

2.  Bacillary  dysentery  (Shiga),  or  one  of  its  strains,  under  which  are 
included  the  sporadic  type  (acute  catarrhal),  which  probably  belongs  to 
this  classification,  as  a  catarrhal  type  (ileocolitis)  exists  in  infants. 

The  diphtheritic  type  is  included  and  also  the  secondary  diphtheritic 
type,  which  may  be  a  terminal  event  in  acute  and  chronic  disease,  and  in 
which  Vedder  and  Duval  have  demonstrated  the  presence  of  the  Bacillus 
dysenteriae. 

Undoubtedly  other  varieties  of  bacteria  play  a  part  in  the  diphtheritic 
type. 

AMEBIC  DYSENTERY 

{Synonym. — Intestinal  Amebiosis) 

Definition. — A  colitis,  latent,  subacute,  acute,  or  chronic,  caused  by 
the  amoeba  dysenteriae.  There  is  a  special  liability  to  formation  of  abscess 
of  the  liver. 

Often  these  cases  occur  without  the  clinical  symptoms  of  dysentery 
at  all.  I  agree  with  Musgrave  that  the  condition  should  be  more  correctly 
given  the  name  of  "intestinal  amebiosis." 

The  disease  is  widely  prevalent  in  Egypt,  India,  the  Philippines, 
West  Indies,  Southern  States,  and  in  tropical  countries.  It  occurs  fre- 
quently in  the  United  States,  and  much  more  in  many  of  our  cities  than 
is  generally  supposed.  I  have  recently  attended  a  case  clearly  infected 
in  New  York  State,  the  patient  having  never  been  south.  The  late 
J.  P.  Tuttle  has  reported  similar  cases,  as  have  H.  S.  Patterson,^  Stockton, 
Graser,  Braunan,  Harvey,^  and  Carey.  It  is  endemic,  especially  in  warm 
climates,  and  often  becomes  epidemic.  Sporadic  cases  occur  in  tem- 
perate climates. 

In  Manila,  Strong  states  that  out  of  1328  cases  in  the  United  States 
army,  561  were  of  the  amebic  type. 

At  the  Johns  Hopkins  Hospital,  Osier  reports  most  of  the  acute  and 
chronic  cases  of  dysentery  were  of  the  amebic  variety;  during  the  first 
fourteen  years  there  were  119  cases  admitted,  95  of  which  came  from 
Maryland — 108  males  an*ii  females. 

Source  of  Infection. — Chiefly  from  contaminated  water  or  green 
vegetables  and  fruit.  Musgrave  has  found  the  ameba  in  ice-cream  and 
water-ices. 

Allen^  reports  two  cases  of  apparent  contact  infection  in  amebiosis, 
probably  from  the  ingestion  of  dried  encysted  amebae.  These  occurred 
in  a  tenement,  the  mother  nursing  a  case,  and  preparing  all  food  for 
the  family,  with  subsequent  development  in  other  children. 

Amoeba  Dysenteriae. — ^Lambl  first  described  amebae  in  the  stools  in 
1859,  and  in  1857  Loesch  investigated  the  stools  of  a  dysenteric  patient 
and  described  the  amebae.  He  injected  the  stools  into  the  intestines  of 
dogs  and  produced  ulceration. 

Osier,  Councilman,  Lafleur,  Dock,  Quincke,  Roos,  Musgrave,  Strong, 
and  many  others  have  carried  on  investigations. 

^  Med.  Rec,  May  14,  1910.  , 

'  N.  Y.  Med.  Jour.,  Jan.  21,  191 1. 
^  Med.  Rec,  Jan,  8,  1910. 


DYSENTERY  669 

To  obtain  a  specimen  for  examination  little  flakes  of  mucus  or  pus 
should  be  selected,  or  the  mucus  may  be  secured  by  passing  a  soft  catheter, 
or  through  a  speculum.  Preferably  a  saline  cathartic  should  be  admin- 
istered, as  suggested  by  Musgrave,  and  the  fluid  portion  of  the  stool 
examined  while  warm.  The  author  in  his  previous  remarks  referred  to  the 
value  of  the  thermos  bottle  to  preserve  a  warm  stool.  The  latter  should  be 
passed  into  a  vessel  previously  warmed  with  hot  water.  A  portion  of  the 
stool,  particularly  that  part  containing  mucus,  should  be  placed  in  the 
thermos  bottle  (or  cheap  vacuum  bottle)  and  a  few  ounces  (2  to  3)  normal 
saline  solution  at  ioi°F.  should  be  added  to  it.     Swollen,  altered  epithelial 


Fig.  287. — Amebae  from  a  culture.     Impression  preparation.     Borrel's  stain  (WooUey 

and  Musgrave). 

cells  must  be  distinguished  from  the  amebae.  The  cells  are  round  with 
granular  protoplasm. 

Amoeba  dysenteries  is  from  15  to  20  microns  in  diameter,  and  consists 
of  a  clear  outer  zone,  or  ectosarc,  and  a  granular  inner  zone  (endosarc), 
and  contains  a  nucleus  and  one  or  two  vacuoles  (Fig.  287).  The 
movements  are  similar  to  an  ordinary  ameba,  consisting  of  a  slight 
protrusion  of  the  protoplasm.  They  vary  somewhat  and  can  be  intensified 
by  having  the  slide  heated.  They  have  a  pale  green  appearance  under 
the  microscope.  Red  blood-corpuscles  are  at  times  contained  in  the  ame- 
bae, and  occasionally  bacteria. 

Musgrave  recommends  Borrel's  stain  for  the  study  of  amebae  in  the 
tissues. 


670  DISEASES   OF    THE    STOMACH   AND   INTESTINES 

They  may  be  in  large  numbers  in  the  tissues.  In  the  pus  of  a  liver 
abscess  amebae  may  be  abundant.  In  the  sputum  from  a  pulmonary  in- 
fection from  an  hepatic  abscess  they  can  be  recognized. 

Quincke  and  Roos  describe  three  varieties  of  amebae  in  the  stools  of 
healthy  persons,  and  Strong  two  types,  only  one  of  which  is  pathogenic. 
Allen^  holds  that  amebae  are  frequently  found  in  the  stools  of  pellagrins, 
and  that  they  may  be  of  a  pathogenic  or  non-pathogenic  variety;  amebiosis 
may  complicate  pellagra  or  the  diagnosis  may  be  confused.  Exclusion  of 
amebiosis  is  necessary. 

Musgrave  and  Clegg  do  not  think  it  has  been  proved  there  are  amebae 
non-pathogenic  to  man.  They  hold  that  all  such  are,  or  may  become, 
pathogenic.  Craig^  believes  the  types  can  be  difiFerentiated  and  Schaudinn 
classifies  two  varieties. 

Amoeba  dysenteriae  can  be  grown  in  cultures  from  stools  or  intestinal 
ulcers,  but  not  alone  as  a  pure  culture.  A  symbiotic  organism  is  necessary 
for  its  development.  It  has  been  isolated  as  a  pure  culture,  in  combina- 
tion with  a  pure  culture  of  another  organism.  Fivea,  Celli,  and  Miller 
claim  to  have  grown  it  pure,  and  that  it  multiplies  by  division. 

Resistant  forms  of  the  ameba  have  been  described  by  Cunningham 
and  Quincke.  They  are  apparently  analogous  to  the  gamete  forms  of  the 
malarial  parasite. 

The  "encysted  amebae"  seem,  under  certain  conditions,  to  be  neces- 
sary for  the  transmission  of  the  disease  from  one  person  to  another,  and 
are  regarded  by  Musgrave  and  Clegg  as  the  most  dangerous  type.  The 
free  unprotected  amebae,  when  swallowed,  are  apparently  destroyed  by 
the  digestive  juices,  while  in  the  encysted  condition  they  pass  through  the 
stomach  and  upper  intestine  unharmed,  and  in  the  large  intestine  grow 
free  and  produce  dysentery.^ 

Cultures  of  amebae  have  withstood  drying  for  fifteen  months. 

Location  of  Lesions. — The  lesions  are  found  in  the  large  intestine, 
rarely  in  the  lower  end  of  the  ileum;  and  abscess  of  the  liver  is  a  common 
accompaniment,  being  present  in  22  per  cent,  of  Osier's  cases. 

Pathology  of  Amebic  Dysentery. — Intestines. — Though  writers  refer  to 
the  classic  undermined  type  of  ulcer  in  amebic  dysentery,  three  types  of 
,  lesions  are  described,  which  may  shade  gradually  into  each  other: 

1.  Pre-idceration. — This  stage  is  characterized  by  the  presence  of  the 
"small  red  dots"  of  Rogers,  varying  from  0.2  to  0.5  mm.  in  diameter,  and 
which  are  intensely  congested  (Fig.  288).  They  consist  of  capillary  hem- 
orrhages into  the  intraglandular  tissue.  Erosion  of  the  superficial  layers 
of  mucous  membrane  is  usually  associated. 

There  is  moderate  injection  of  the  mucous  membrane  and  but  little 
thickening  of  the  submucosa.  These  lesions  may  be  seen  in  any  part  of 
the  aflfected  gut,  and  chiefly  in  the  acute  cases.  In  view  of  the  presence 
of  this  pre-ulcerative  stage,  Musgrave  believes  that  sometime  in  the  future 
we  may  recognize  an  amebic  colitis  without  ulceration  of  the  mucosa. 

2.  Ulceration  {type  of  Harris)  rarer  than  the  classic  type,  and  believed 

^  N.  Y.  Med.  Jour.,  Dec.  18,  1909. 

*  Jour.  Infec.  Dis.,  June  4,  1908,  v,  324. 

'  Marshall,  Jour.  Amer.  Med.  Assoc,  April  23,  1910. 


DYSENTERY 


671 


Fig.  288.— Intestinal  araebiosis.  Cecum.  Shows  all  stages  of  ulceration.  The 
smallest  black  points  indicate  the  positions  of  pre-ulcerative  lesions  (WooUey  and 
Musgrave). 


Fig.  289.— Intestinal    amebiosis.     Rectum.     Extensive    ulceration    and    diphtheritis. 
Thick-walled  gut  (VVooUey  and  Musgrave). 


672  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

to  be  intermediate  between  the  petechias  and  "undermined"  ulcer.  They 
are  probably  the  result  of  the  superficial  erosions,  and  are  primarily  con- 
fined to  the  mucous  membrane,  though  they  reach  into  the  submucosa 
or  to  the  circular  muscle,  but  no  deeper  (Fig.  290).  They  spread  laterally. 
The  ulcer  has  a  punched-out  appearance  and  is  round  or  oval,  the  edges 
thick  and  congested.  Base  is  clean,  gray  and  edematous.  They  often 
lie  at  the  apex  of  the  intestinal  fold  and  tend  to  increase  in  the  direction 
of  the  short  axis  of  the  bowel,  and  are  found  in  all  regions,  but  less  often 
in  the  advanced  or  chronic  cases.  They  are  most  common  in  the  ileum. 
3.  Classic  or  Undermined  Ulcers. — In  the  early  stage  they  appear  as 
minute  yellow  or  gray  spots  in  the  mucosa,  at  times  at  the  centers  of 


Fig.  290. — Early  intestinal  lesion.  Shows  superficial  necrosis,  glandular  dis- 
tortion, and  round-cell  infiltration.  Borrel's  stain.  Zeiss  obj.  A,  A,  oc.  comp.  4 
bellows  at  30  cm.  (WooUey  and  Musgrave). 

"Rogers'  red  dots,"  and  are  usually  surrounded  by  a  congested  area. 
These  spots  are  the  mouths  of  passages  leading  to  cavities  in  the  sub- 
mucosa; the  mouths  and  cavities  are  filled  with  necrotic  material. 

As  the  ulcerative  process  extends,  the  cavity  in  the  submucosa  is 
enlarged,  and  though  the  necrobiosis  eventually  involves  all  the  coats,  the 
muscular  layers  and  mucosa  are  affected  less  rapidly,  and  the  latter  may 
be  markedly  undermined.  The  ulcers  may  gradually  coalesce  on  the  sur- 
face, or  quite  frequently  the  cavities  in  the  submucosa  may  communicate 
with  each  other  by  tunnels,  while  the  mucous  membrane  shows  a  catarrhal 
condition.  The  submucosa  becomes  thickened  and  edematous,  as  do 
often  the  muscular  layers  and  peritoneal  coat  (Fig.  291). 

The  ulcers  may  be  from  the  size  of  a  pin-head  to  the  palm  of  the  hand. 


DYSENTERY 


673 


In  extensive  ulceration  the  muscular  layer  may  become  necrosed  or  even 
perforated,  and  the  base  of  the  ulcer  be  formed  by  peritoneum  or  omentum. 
The  omentum  plays  an  important  protective  part,  being  frequently,  early 
in  the  ulcerative  stage,  found  adherent  to  the  surface  of  the  intestines. 
Localized  suppuration  is,  therefore,  common.  Ulcers  may  perforate  into 
the  subperitoneal  or  retroperitoneal  tissue.  They  are  usually  circum- 
scribed, though  they  may  burrow  (Fig.  292). 


Fig.  291.— Colon.  A  moderately  thick 
ened  gut  with  various  types  of  ulcers  (Wool 
ley  and  Musgrave). 


Fig.  292. — Culuii.  1  hin-walled  gut, 
with  shallow  ulcers,  some  slightly  un- 
dermined, others  punched  out  (Woolley 
and  Musgrave). 


Healing  Process. — In  the  case  of  the  small  ulcers  there  may  be  complete 
repair,  the  epithelium  from  the  mucous  membrane  lining  the  ulcer,  except 
its  base.  In  larger  ulcers  there  may  be  considerable  scar  tissue,  which 
may  lead  to  contraction.  J.  Cantlie,'  in  the  Journal  of  Tropical  Medicine, 
suggests  that  amebic  infection  is  probably  much  more  common  than  is 
usually  supposed.     It  is  known  that  quite  extensive  infection  can  exist 


1  .\mer.  Med.,  March,  19 10. 


43 


674  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

without  symptoms.  He  believes  that  some  cases  of  stricture,  or  cancer 
of  the  sigmoid  and  rectum  especially,  may  be  postdysenteric  conditions. 

According  to  Musgrave's  observation,  there  is  established  in  cases  of 
long  duration  not  systematically  treated,  a  chronic  catarrhal  condition  with 
subsequent  atrophy  (enteritis  chronica  atrophicans),  a  thinness  of  the 
bowel,  absence  of  normal  folds,  atrophy  of  the  mucosa,  and  increased 
length;  and  he  places  it  in  the  classification  of  sprue  or  psilosis,  believing 
untreated  amebiosis  to  be  one  of  the  causes  of  this  condition.  There  may 
be,  on  the  other  hand,  in  some  cases  localized  hypertrophy  with  well- 
developed  polypi. 

Location  of  the  Lesions. — Harris  believes  that  in  fully  one-half  the  cases 
the  lesions  do  not  extend  beyond  the  beginning  of  the  transverse  colon; 


Fig.  293. — Amebae  in  a  blood-vessel;  X  500.     Heidenhain  iron  hematoxylin  (Woolley 

and  Musgrave). 

while  Rogers  holds  that  they  are  more  frequently  limited  to  the  cecum 
and  ascending  colon.  The  ileum  just  above  the  ileocecal  valve  is  rarely 
involved,  and  generally  by  only  a  few  ulcers  (superficial)  and  a  slight  in- 
volvement may  occur  if  diphtheritic  inflammation  complicates.  The 
lower  rectum  is  rarely  involved. 

Strong  and  Musgrave,  comparing  200  cases  treated  and  untreated, 
find  159  cases  involve  the  entire  large  bowel,  excepting  the  lower  rectum; 
23,  the  cecum  and  ascending  colon;  2,  the  transverse  colon;  the  descending 
colon,  sigmoid,  and  rectum,  9;  unrecorded,  7;  appendix  ulcerated,  2 
(amebic);  appendix  involved  with  large  intestine,  14;  ileum  with  large 
intestine,  7. 

The  presence  or  absence  of  irrigation  treatment  makes  a  difference. 


DYSENTERY  675 

In  cases  dying  early  from  intermittent  disease,  ulceration  in  the  cecum 
and  ascending  colon,  11;  in  descending  colon,  sigmoid,  and  rectum,  8;  in 
the  entire  bowel,  6. 

Microscopic. — Mucous  membrane  between  the  ulcers  is  little  changed. 
In  the  neighborhood  of  the  lesions  a  tendency  to  hypertrophy  with  mucoid 
degetieration  and  cyst  formation.  In  the  early  lesions,  congestion  with 
capillary  hemorrhages  and  edema  of  the  mucosa;  increase  of  lymphoid 
cells  in  the  interglandular  tissue. 

Amebae  from  4  to  35/i  long  are  present  in  the  glands,  interglandular 
tissues  and  blood-vessels,  muscularis  mucosa,  and  in  the  veins  of  the  sub- 
mucosa  (Fig.  293). 

In  the  more  advanced  condition  there  is  necrobiosis  (coagulation 
necrosis)  in  the  ulcers,  with  lymphoid  infiltration,  congestion  and  throm- 
bosis, and  very  little  polymorpholeukocytic  invasion.  The  amebae  secre- 
tion and  thrombosis  both  tend  to  produce  the  necrobiosis. 

If  there  is  marked  polymorphonuclear  infiltration,  pathogenic  bacteria 
are  playing  an  active  part  in  the  process;  noticeably  then  there  is  diph- 
theritic inflammation  (Fig.  289)  or  gangrene.  When  amebae  are  found  in 
exudates  rich  in  bacteria,  they  show  evidences  of  active  phagocytosis. 
In  some  cases  there  are  many  bacteria,  but  they  are  probably  non-patho- 
genic, as  marke  1  leukocytosis  was  not  present  and  no  process  could  be 
seen  to  be  attributed  to  them. 

"In  efifect,  intestinal  amebiosis  may  be  said  to  be  rather  a  subacute 
chronic  inflammatory  process,  as  was  demonstrated  by  the  character  of 
the  exudate  and  infiltration,  by  the  early  formation  of  granulation  tissue, 
and  by  the  absence  of  leukocytic  infiltration,  a  notable  absence  of  puru- 
lent inflammation.  This  applies  to  the  cases  not  complicated  by  diph- 
theritic process  or  gangrene"  (Musgrave). 

If  the  diphtheritic  process  is  associated,  some  strain  of  the  bacillary 
type  is  probably  responsible;  and  if  gangrene,  some  otlter  bacteria  (mixed 
infection). 

Lesions  (Abscesses)  of  the  Liver. — There  may  be  local  necroses  of  the 
parenchyma  scattered  throughout  this  organ,  due  to  probable  chemic 
products  of  the  amebae,  and  also  abscesses. 

This  is  quite  a  common  complication  of  amebic  dysentery,  and  occurred 
in  27  out  of  Osier's  119  cases.  In  most  cases  the  right  lobe  is  involved 
either  alone  or  with  other  portions.  In  40  per  cent,  to  65  per  cent,  the 
abscess  is  solitary,  particularly  in  the  dome  of  the  right  lobe.  In  the 
majority  of  cases  the  abscesses  lie  rather  close  to  the  surface.  Under 
ten  years  of  age  and  over  sixty,  they  are  rare.  They  occur  most  frequently 
in  young  adult  males.  Abscess  of  the  liver  is  infrequent  among  the  natives 
such  as  the  Filipinos  and  rare  among  the  Chinese,  though  intestinal  ame- 
biosis is  prevalent.  Amebic  a'bscess  is  most  apt  to  occur  among  the 
unacclimated. 

The  portal  venous  system  is  the  usual  channel  of  transmission  of  the 
amebae  to  the  liver,  though  occasionally  they  may  follow  directly  con- 
tinuous tissue. 

Most  of  the  so-called  amebic  liver  abscesses  are  really  local  necroses 
and  no  pus  at  all.     They  may  be  single  or  multiple;  when  single,  the  right 


676  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

lobe  is  most  commonly  affected  on  the  convex  surface  near  the  attachment 
to  the  diaphragm,  or  on  the  concave  surface  near  the  bowel. 

Multiple  abscesses  (small  and  superficial),  miliary,  containing  amebae, 
may  be  scattered  throughout  the  liver  substance. 

The  hepatic  abscess,  though  it  often  occurs  within  the  first  two  to 
three  months  after  the  onset  of  the  dysentery,  in  some  cases  may  not 
appear  for  several  years.  Some  cases  are  reported  as  occurring  when  no 
dysenteric  symptoms  had  apparently  been  complained  of  by  the  patient. 

In  the  early  stage  the  abscesses  are  a  grayish-yellow  color,  sharply 
defined  in  shape,  and  contain  a  spongy  necrotic  material,  with  more  or  less 
glairy  semitransparent  fluid  in  the  interstices.  The  larger  abscesses  have 
ragged  necrotic  walls  and  contain  a  viscid  greenish-yellow  or  reddish- 
yellow  purulent  appearing  material,  mixed  with  blood  and  shreds  of  liver 
tissue. 

Old  abscesses  of  a  chronic  type  have  a  dense  fibrous  wall.  The  outer 
zone  is  hyperemic;  the  midzone  shows  proliferations  of  connective-tissue 
cells,  compression  and  atrophy  of  the  liver  cells,  and  an  inner  necrotic 
zone.  There  is  the  same  absence  of  true  purulent  inflammation  as  in  the 
intestines,  except  where  there  is  a  secondary  infection  with  pyogenic 
organisms.     When  the  latter  are  present,  we  have  purulent  accumulations. 

The  contents  of  the  necrotic  type  of  abscess  show  fatty  and  glandular 
detritus,  necrotic  hepatic  cells,  amebae,  and  occasionally  Charcot-Leyden 
crystals.  Amebae  are  also  found  in  the  abscess  walls.  Cultures  are 
frequently  sterile. 

Micrococci  and  bacilli  may  be  found,  notably  the  Staphylococcus 
aureus,  Streptococcus  pyogenes,  Bacillus  coli  (with  other  organisms), 
Bacillus  pyocyaneus,  and  Micrococcus  lanceolatus,  and  rarely  pneumo- 
cocci.  Bacteria  are  more  commonly  associated  with  amebae  in  the 
multiple  abscesses. 

The  abscess  most  frequently  points  upward  and  ruptures  into  the 
right  lung.  In  some  cases  an  empyema  may  be  produced  or  a  pyopneumo- 
thorax. Perforation  may  occur  in  other  directions,  into  the  pericardium, 
peritoneum,  stomach,  intestines,  portal  or  hepatic  veins,  inferior  vena 
cava,  kidney,  psoas  muscle,  bladder,  spleen,  gall-bladder,  retro-peritoneal 
tissue,  or  externally.  If  bacteria  are  associated  'with  amebic  abscesses, 
death  may  result  from  sepsis  within  a  short  time,  while  patients  with  a 
single  simple  amebic  abscess  may  remain  in  fair  health  for  several  years. 

Symptoms  and  Diagnosis  of  Amebic  Abscess  of  the  Liver. — Sometimes 
there  are  slight  symptoms,  even  with  large  abscess,  and  even  exploratory 
puncture  may  not  avail.  Exploratory  puncture  is  the  surest  method  at 
our  command,  with  examination  of  the  contents  of  the  abscess  for  the 
amebae. 

Physical  Signs. — The  liver  usually  shows  some  enlargement  particularly 
if  the  right  lobe  is  involved,  and  the  enlargement  is  more  usually  upward. 
Fever — remittent,  intermittent  or  continuous — is  usually  present.  Septic 
temperature  is  due  to  mixed  infection.  Leukocytosis  and  increased  poly- 
nuclears  are  present,  though  Musgrave  believes  they  are  given  an  undue 
importance,  as  the  intestinal  infection  alone  may  be  responsible  for  them. 
The  pain  of  amebic  abscess  is  rarely  acute  and  is  more  of  the  nature  of  a 


DYSENTERY 


677 


general  soreness  over  the  liver  and  there  is  tenderness  on  pressure  over  its 
lower  border,  or  over  the  gall-bladder.  If  the  abscess  is  subdiaphragmatic; 
pain  is  usually  increased  by  change  of  position,  particularly  on  lying  on 
the  left  side  or  on  standing.  Pain  is  not  so  frequently  referred  to  the  shoul- 
der. Local  pains  are  most  pronounced.  Respiratory  disturbances  occur 
when  abscesses  rupture  into  the  lung  or  pleura.  Jaundice  of  a  marked 
type  is  rare  with  solitary  abscess  and  not  very  frequent  with  multiple  ones. 
A  slight  subicteric  tinge  is  quite  common.  Except  with  sepsis,  there  are 
no  important  stomach  symptoms.  There  may  be  nausea  and  rarely 
vomiting.  There  is  frequently  an  increase  in  the  number  of  bowel  move- 
ments during  the  development  of  liver  abscess. 

Abscess  in  OtJwr  Locations. — (i)  Spleen. — Amebic  abscess  of  this  organ 
may  rarely  occur.  Rogers^  reports  such  cases  cured  by  aspiration  and 
emetin  injections.  (2)  Abscesses  more  generally  result  from  perforation 
and  may  occur  anywhere  from  the  region  of  the  cecum  to  the  rectum. 
They  may  involve  the  appendix,  perirenal  tissue,  psoas  muscle,  kidney 
and  abdominal  wall.  Along  the  descending  colon,  they  may  be  of  the 
dissecting  type  and  may  cause  it  to  slough  away,  or  there  may  be  small 
abscesses  in  the  anterior  surface  of  the  colon.  Ischio-rectal  abscess  may 
occur. 

Complicating  Bacteria  and  Intestinal  Parasites. — Bacillus  dysenteriae 
(Shiga)  diphtheritic  processes  due  to  streptococci,  etc.,  balantidium  coli, 
strongyloides  intestinalis,  oxyuris,  trichomonas,  circomonas,  megastoma 
entericum,  tenia,  trichiuris,  ascaris  and  other  parasites  may  occur  with 
amebic  dysentery. 

S3miptoms. — There  has  been  a  tendency  to  arbitrarily  divide  amebic 
dysentery  into  two  clinical  types,  the  acute  and  the  chronic,  and  to  create 
the  impression  that  in  acute  and  chronic  dysentery  we  have  necessarily 
diarrhea,  or  diarrhea  alternating  with  constipation,  the  passage  of  blood 
and  mucus,  and  the  presence  of  tenesmus.  Unquestionably,  latent  and 
masked  infections,  with  intestinal  amebiosis  are  by  no  means  rare, 
and  marked  pathologic  changes  may  be  present  without  objective  clinical 
symptoms. 

Councilman,  Lafleur,  Osier,  Dock,  Strong,  and  Musgrave  have  reported 
such  cases.  The  latter  notably  refers  to  one  case,  treated  six  months  for 
constipation,  in  whom  autopsy  showed  perforation  of  a  liver  abscess  as 
the  cause  of  death,  with  associated  lesions  (amebic  ulceration)  of  the 
cecum  and  ascending  colon. 

The  early  recognition  of  these  irregular  types  is  of  great  importance, 
especially  when  amebic  dysentery  is  endemic.  Unquestionably,  some  of 
our  old  cases  of  apparently  simple  catarrhal  colitis  are  of  this  type.  In 
fact,  I  have  had  one  experience  with  such  a  case,  where  amebae  were  found 
present,  with  ultimate  recovery  under  appropriate  treatment. 

Since  many  of  the  cases  may  present  no  clinical  symptoms  of  amebic 
dysentery,  I  believe  Musgrave's^  classification,  under  "Intestinal  Amebi- 
osis," to  be  the  most  scientific. 

I.  Latent  and  masked  infections  with  the  amebae. 

1  Brit.  Med.  Jour.,  Aug.  24,  191 2. 

*  Jour,  of  Amer.  Med.  Assoc,  Sept.  16,  1905. 


678  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

2.  Mild  and  moderately  severe  infections  (subacute  dysentery), 

3.  Severe  infection,  including  gangrenous  and  diphtheritic  types  (acute 
dysentery). 

4.  Chronic  dysentery. 

5.  Infection  in  children  and  in  the  aged. 

Latent  Infection. — In  these  cases,  there  is  a  pathologic  amebic  process 
in  the  intestines,  without  any  diarrhea  or  any  other  symptoms  that  would 
indicate  the  infection. 

Musgrave  has  demonstrated  that  the  symptoms  pointing  to  dysentery 
may  be  absent  for  a  long  time,  yet  there  are  certain  symptoms  which  sug- 
gest the  condition. 

Dull,  aching  abdominal  pains  are  present,  which  are  attributed  to  catch- 
ing cold.  They  first  appear  and  are  most  active  during  the  night  or  early 
morning.  Indigestion,  headache,  lassitude,  coated  tongue,  and  a  foul 
breath  are  present.  There  are  loss  of  appetite,  some  loss  of  weight,  loss 
of  color,  and  at  times  a  yellow  skin. 

Physical  examination  discloses  on  deep  palpation  tenderness  along  the 
colon,  especially  over  the  cecum  and  ascending  colon.  This  last  is  a  signifi- 
cant symptom;  occasionally  thickened  intestines  can  be  made  out.  If  a 
hydragogue  cathartic  be  administered,  there  will  be  present  in  the  stool 
amebge,  mucus,  tissue  elements,  and  often  old  blood. 

Musgrave  has  demonstrated  by  autopsy  on  his  fatal  latent  cases,  that 
the  lesions  are  in  the  cecum  and  ascending  colon.  Any  patient,  therefore, 
living  where  amebic  dysentery  is  endemic,  suffering  from  the  symptoms 
referred  to,  should  be  given  a  saline  cathartic  and  the  stool  carefully 
searched  for  amebge.  The  possibility  of  amebic  injection  in  chronic  colitis 
with  no  diarrhea  should  be  considered  in  New  York.  I  have  already 
referred  to  a  patient  infected  in  that  State.  On  the  other  hand,  some  of 
the  latent  cases,  if  untreated,  may  later  develop  the  symptoms  of  amebic 
dysentery. 

Under  the  same  class  of  cases  (latent)  in  regions  where  amebiosis  is 
endemic,  we  may  have  patients  in  whom  other  symptoms,  such  as  chronic 
constipation,  gastric  symptoms,  or  even  appendicitis,  may  mask  the  in- 
testinal amebiosis.     Musgrave  has  reported  such  cases. 

Mild  and  Moderately  Severe  Cases  {Subacute  Dysentery). — Mild  Cases. 
— These  frequently  develop  from  the  latent  type,  and  often  present  the 
aspects  of  a  diarrhea  and  not  of  dysentery.  Abdominal  pain,  tenderness 
along  the  colon,  headache,  digestive  disturbances,  irritability,  melan- 
cholic condition,  anemia,  and  loss  of  weight  are  present. 

Amebse  are  found  in  the  diarrheal  movements.  Some  of  these  cases 
never  show  dysenteric  movements,  even  without  treatment.  This  type 
Musgrave  believes  often  becomes  chronic;  while,  on  the  other  hand,  chronic 
gastro-enteritis  or  "sprue"  may  be  the  ultimate  outcome,  giving  their 
clinical  pictures.  The  patient  usually  dies  from  intermittent  disease  or 
complications. 

Moderately  Severe  Cases  {Subacute  Dysentery). — In  these  cases  with  the 
symptoms  just  described,  there  may  be  a  diarrhea  more  marked  in  the 
morning,  consisting  of  several  semifluid  stools,  no  mucus  or  blood,  and 
passed  without  pain.     This  may  intermit  with  constipation.     Finally,  the 


DYSENTERY  679 

attack  may  increase  in  intensity,  and  mucus  and  blood  will  appear.  In 
other  cases  they  will  occur  from  the  onset.  Usually  the  more  acute  the 
onset,  the  more  rapidly  the  severe  symptoms  develop. 

Severe  Cases  {Acute  Dysentery). — These  are  the  classical  cases  usually 
described.  Diphtheritic  and  gangrenous  processes,  due  to  some  secondary 
infection,  are  most  common  in  this  type.  In  the  most  serious  cases,  por- 
tions of  the  large  intestine  may  be  felt  through  the  abdominal  wall  as 
very  tender,  greatly  thickened  sausage-shaped  or  rounded  masses,  showing 
that  the  entire  thickness  of  the  gut  is  involved.  This  class  of  cases  is 
nearly  always  accompanied  by  -an  extremely  high  leukocytosis  from  30,000 
to  50,000,  though  more  moderate  leukocytosis  is  at  times  present. 

The  onset  is  usually  quite  sudden,  whether  primary,  or  following  on  a 
milder  type.  There  are  marked  abdominal  colic;  diarrhea;  tenesmus, 
which  may  be  constant  and  very  painful;  straining,  and  then,  finally, 
passages,  chiefly  of  small  quantities  of  mucus  and  blood.  In  some  cases 
the  dejecta  are  hemorrhagic,  consisting  of  pure  blood  or  dark  and  coagu- 
lated blood.  Sloughs  are  passed  in  others,  consisting  of  gray  or  blackish 
masses  of  necrotic  tissue  6f  very  foul  odor. 

The  temperature,  as  a  rule,  is  not  high.  The  patient  rapidly  emaciates, 
and  the  heart  becomes  rapid  and  feeble. 

Death  may  occur  in  severe  cases  within  a  week  from  the  onset.  There 
may  be  gangrene  of  the  intestine  or  a  post-colic  abscess  form  with  resulting 
fatal  termination.  Hemorrhage  (intestinal)  or  perforative  peritonitis  may 
take  place.  Many  cases  recover,  but  some  become  chronic.  In  others 
extensive  ulceration  may  remain  after  sloughing  and  the  diarrhea  con- 
tinues, the  patient  rapidly  emaciating,  and  finally  dying  exhausted  within 
a  couple  of  months.  Emaciation  is  very  marked  in  these  patients.  Cor- 
neal ulceration  may  occur. 

Stools. — As  many  as  twenty  to  thirty  may  be  passed  in  twenty-four 
hours,  colicky  pains  usually  precede  them,  and  they  are  followed  by 
straining  and  severe  tenesmus.  Movements  at  first  are  copious,  later 
scanty,  and  consist  chiefly  of  mucus  and  blood.  Intermissions  and  ex- 
acerbations of  diarrhea  occur,  gangrenous  dejecta,  dark  red  brown  and 
containing  gray  or  black  fragments  of  tissue  (foul  in  odor),  may  be  passed, 
or  pure  blood.     Amebas  are  present  in  the  stools. 

Abdominal  Pains. — These  are  quite  severe,  chiefly  before  evacuation, 
and  sometimes  they  are  continuous.  They  are  frequently  located  in  the 
umbilical  region  and  left  iliac  fossa;  at  times  in  the  right  iliac  fossa,  and 
may  simulate  appendicitis.     Pressure  increases  the  pain. 

Tenesmus. — This  consists  of  pressure  and  constriction  in  the  rectum 
and  a  desire  to  go  to  stool.  It  may  be  continuous  and  accompanied  by 
dysuria  or  strangury. 

Other  Symptoms. — Fever  may  occur,  generally  of  moderate  type,  and 
it  may  be  accompanied  by  chills  at  the  onset.  Temperature  is  irregular. 
Anorexia,  nausea,  and  vomiting  may  occur.  There  may  be  severe  pros- 
tration, cold  extremities,  delirium,  stupor,  drowsiness,  and  cerebral  dis- 
orders. 

Chronic  Dysentery. — This  type  of  dysentery  shows  several  forms.  It 
may  be  rather  mild,  characterized  chiefly  by  diarrhea,  with  no  blood  or 


68o  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

tenesmus,  following  on  the  mild  t3^e  previously  described.  This  may- 
continue  a  number  of  years. 

Dysentery  in  more  marked  cases  is  subacute  from  the  onset,  or  gradu- 
ally passes  into  the  chronic  stage.  There  are  generally  alternating  periods 
of  diarrhea  and  constipation  covering  several  years.  During  the  exacer- 
bations there  are  pain,  passages  of  blood  and  mucus,  tenesmus,  and  a 
slight  rise  of  temperature.  Many  such  cases  do  not  feel  especially  ill 
between  attacks  and  keep  fairly  well  nourished.  The  appetite  is  often 
irregular  in  this  type,  and  errors  in  diet  are  followed  by  exacerbations  of 
the  disease.     The  tongue  is  red,  glazed,  and  beefy. 

In  more  severe  cases  emaciation  may  be  extreme  and  the  patient  be 
confined  to  bed  most  of  the  time.  There  are  loss  of  appetite  and  nausea; 
diarrhea  is  quite  persistent,  there  being  mucus  or  mucus  and  blood  in  the 
stools,  with  attacks  of  colic  and  tenesmus.  There  may  be  some  periods 
of  improvement. 

Infection  in  Children  and  in  the  Aged. — Musgrave  reports  cases  in 
children  from  the  age  of  six  months  to  ten  years  in  the  Philippines.  Chil- 
dren seem  to  present  a  natural  immunity,  he  believes,  and  when  infection 
does  occur,  it  seems  of  a  mild  type  and  readily  yields  to  treatment. 

The  symptoms  resemble  those  of  the  mild  type  in  adults.  In  the 
aged  there  also  seems  to  be  a  natural  immunity,  but  when  the  disease  was 
established  it  ran  a  severe  and  rapid  course. 

Liver  abscess  is  infrequent  in  the  very  young  and  aged;  Musgrave  notes 
it  is  infrequent  in  the  natives. 

The  only  certain  method  of  diagnosis  is  by  microscopic  examination 
of  the  feces  or  discharges  and  finding  the  amebae. 

Other  parasites  are  found  at  times  associated  with  the  amebae,  such 
as  the  trichomomedae,  ova  of  uncinariae,  embryo  strongyloides,  tenia, 
oxyuris,  etc. 

Circulatory  System. — The  pulse  may  be  of  good  quality  at  first;  later, 
rapid  and  feeble.  There  are  the  changes  of  secondary  anemia.  Early, 
the  blood  is  normal;  later,  the  red  cells  are  those  of  anemia.  Still  later, 
they  may  become  irregular  in  size  and  shape  and  the  count  be  reduced. 

Leukocytes. — An  increase  in  polynuclears  and  eosinophiles  may  occur. 
Hemoglobin  decreases  with  the  red  cells.     Spleen  is  usually  not  enlarged. 

Temperature  may  be  absent,  moderate,  or  intermittent.  In  cases 
that  are  complicated,  especially  if  there  is  diphtheritic  inflammation  of 
the  colon,  it  may  become  quite  high.  With  liver  abscess  temperature  is 
frequent,  but  not  constant.  If  there  is  mixed  infection  in  the  liver,  bac- 
teria with  the  amebae,  the  temperature  may  be  intermittent  or  remittent 
and  resemble  malaria  or  endocarditis.     Sometimes  it  may  be  subnormal. 

Nervous  System. — Neuritis  and  neuralgias  may'be  present. 

Pain. — This  varies  in  type  and  intensity. 

Tenesmus. — More  often  it  is  an  indication  of  secondary  involvement 
or  complications.  It  is  never  present  in  the  latent  forms,  and  is  often 
absent  or  very  slight  in  the  moderately  severe  cases. 

In  acute  cases  with  diphtheritic  process  or  secondary  infection,  as  from 
Bacillus  dysenteriae  (Shiga),  it  may  be  severe.  It  is  more  likely  absent 
when  the  lesions  are  in  the  cecum  or  upper  colon. 


DYSENTERY  68 I 

Colicky  pains  frequently  occur,  and  at  times  severe  colic. 

The  dull,  aching  abdominal  pain  is  often  prodromic  and  persists  during 
the  course  of  the  disease,  at  times  interfering  with  the  patient's  rest. 
The  greatest  intensity  is  usually  along  the  colon,  as  demonstrated  by 
palpation.  Sometimes  it  is  confined  to  the  cecum.  It  may  be  complained 
of  in  the  back.  It  is  probably  due  to  the  ulcerative  process  in  the  bowel 
and — ^as  demonstrated  in  the  latent  cases,  as  shown  by  postmortem — is 
the  only  indication  during  life  of  serious  lesions.  These  pains  are  often 
the  worst  at  night. 

Burning  pains  ("heart-burn  in  the  abdomen"),  Musgrave  states,  may 
be  general  or  local;  when  the  disease  is  in  the  sigmoid  or  rectum  these 
pains  may  be  intense,  and  extend  down  the  backs  of  the  thighs  to  the 
calves,  and  old  cases  of  sciatica  may  be  started  up.  Musgrave  holds 
that  the  beginning  of  sciatica,  associated  with  such  cases,  is  of 
sufficiently  frequent  occurrence  to  be  suggestive. 

Appendicitis  pains  are  at  times  simulated,  but  examination  will  show 
that  the  tenderness  is  located  in  the  caput  coli.  The  differential  method 
by  Morris'  point  would  be  of  value  in  these  cases,  as  described  under 
Appendicitis. 

Neuralgia,  myalgia,  and  arthralgia  may  be  present.  There  is  per- 
sistent dull  headache  in  the  back  of  the  head  and  neck. 

The  genito-urinary,  respiratory,  and  special  senses  are  rarely  involved, 
as  is  also  true  of  the  joints  and  osseous  systems,  though  complications 
may  occur. 

Complications  of  Amebic  Dysentery. — Malaria,  beri-beri,  tuberculosis, 
Bright's  disease,  pernicious  anemia,  leukemia,  specific  bacterial  dysentery, 
chronic  rheumatism  and  certain  nervous  affections  may  occur  in  associa- 
tion with  amebic  dysentery.  Cancrum  oris  occasionally  complicates, 
though  it  is  more  frequent  with  the  bacillary  or  streptococci  types.  Stom- 
atitis and  esophagitis  occur  more  frequently  as  after-effects,  though  some- 
times earlier.  There  may  be  gastralgia,  gastritis,  achylia  gastrica,  hyper- 
chlorhydria,  gastric  ulcer,  arteritis  and  reversed  intestinal  peristalsis,  the 
latter  from  local  treatment,  renal  complications,  amebic  infection  of  the 
urinary  bladder,  hemorrhoids,  fissure,  fistulae,  dilatation  of  part  of  the 
colon,  occasionally  general  dilatation  of  the  large  intestine,  and  cicatricial 
contraction  from  healed  amebic  ulcers.  Perforation  of  intestinal  ulcers 
occurs  with  untreated  and  fatal  cases,  but  is  rare  when  proper  treatment 
has  been  instituted  early.  Intestinal  hemorrhage  of  severe  type  is  rare  with 
amebic  dysentery  and  is  liable  to  be  associated,  when  occurring,  with  liver 
abscess  or  with  the  diphtheritic  type. 

Amebic  Appendicitis. — This  condition  has  been  reported  by  several 
writers. 

Etiology. — Amebic  appendicitis  is  nearly  always  an  extension  of  the 
amebic  process  from  the  cecum,  and  has  a  marked  relation  to  infection  on, 
and  above,  the  valve  of  Bauhini.  It  does  not  develop  early  in  the  disease 
and  most  often  attacks  a  normal  appendix.  It  occurs  most  frequently 
with  severe  dysenteric  infection,  such  as  when  the  amebic  is  complicated 
by  the  diphtheritic  or  gangrenous  type  (the  mixed  infections). 

Morbid  Anatomy, — The  lesions  in  the  appendix  resemble  those  in  the 


682  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

bowel,  but  are  small  and  more  superficial.  The  ulcers  are  rarely  along  the 
meso-border,  though  they  sometimes  extend  nearly  around  the  mucosa. 
The  appendix  is  usually  patulous,  with  a  large  lumen,  and  concretions  are 
the  exception.  There  are  moderate  engorgement  and  injection  of  the 
blood-vessels,  so  that  external  evidences  of  inflammation  are  not  very 
marked. 

Symptoms. — The  symptoms  of  amebic  appendicitis  resemble  those  of 
acute  appendicitis,  but  are  as  a  rule  less  severe,  thus  tenderness  at  Mc- 
Burney's  point,  but  less  rigidity  of  the  abdominal  muscles;  the  tumor  mass 
is  not  so  sharply  circumscribed  and  the  fever  and  general  prostration  are 
less  marked.  There  are  fulminating  cases  which  cannot  be  distinguished 
from  other  t5^es.  The  leukocyte  count  is  not  of  a  great  value  in  amebic 
appendicitis,  since  leukocytosis  occurs  with  intestinal  amebiosis.  Appen- 
dicitis (non-amebic)  may  also  complicate  amebic  dysentery. 

Differential  Diagnosis. — Severe  Amebic  Infection  of  Colon,  or  Cecum 
and  Ascending  Colon. — The  fever,  leukocytosis,  nausea,  vomiting, 
abdominal  tenderness,  etc.,  would  suggest  appendicial  involvement  but  the 
history,  absence  of  rigidity  of  the  abdominal  muscles,  the  diffused  area  of 
tenderness,  and  the  location  and  character  of  the  thickened  intestine 
usually  furnish  the  diagnosis.  Operation  is  useless  in  these  cases,  inter- 
fering with  the  treatment  of  the  dysentery.  Disease  of  the  lower  ileum 
cannot  be  accurately  diagnosed.  Gaseous  distention  and  fecal  accumula- 
tion in  the  cecum  may  cause  local  pain,  and  suggest  appendicial  inflamma- 
tion, but  an  active  cathartic  will  relieve  the  condition.  A  localized  peri- 
tonitis and  adhesions  about  the  cecum  can  usually  be  determined  particu- 
larly when  the  bowel  is  empty.  Pericecal  amebic  abscess  may  occur. 
Fecal  impaction  with  distention  of  the  cecum  and  neuralgic  pains  must  be 
differentiated  from  appendicitis. 

Anatomic  displacements  and  malformations  such  as  enteroptosis,  an 
unusually  long  mesentery,  and  flexures  of  the  sigmoid  and  rectum,  may 
interfere  with  bowel  irrigation. 

Acute  general  peritonitis  may  follow  perforation  of  an  ulcer  of  the 
colon,  of  the  appendix,  or  of  a  liver  abscess,  or  without  any  perforation, 
but  perforation  of  an  ulcer  is  usually  walled  off  by  omentum,  without 
producing  a  general  peritonitis. 

Chronic  localized  adhesive  peritonitis  is  one  of  the  most  frequent  com- 
plications of  amebic  infection.  It  may  be  slight  or  extensive  and  gives 
rise  to  all  the  varieties  of  adhesions— omentaX  or  between  the  viscera,  or  to 
the  abdominal  wall  or  diaphragm — which  may  occur  within  the  abdomen. 
The  chief  symptoms  of  these  adhesions  are  abdominal  pain,  soreness  and 
intestinal  stasis  in  some  cases.  Strangulation  of  the  small  or  large  intes- 
tine, complete  or  partial,  most  frequently  below  the  splenic  flexure,  may 
occur.  Phlebitis,  emboli,  venous  thrombosis  and  infarctions  of  the  liver, 
spleen,  intestines  and  kidneys  have  occurred.  Chronic  rheumatism,  both 
articular  and  muscular,  is  frequently  met  with  and  seems  to  bear  a  definite 
relation  to  amebiosis.  It  is  particularly  apt  to  develop  in  cases  of  dysen- 
tery of  long  duration,  while  in  other  cases  a  pre-existing  rheumatism  is 
rendered  much  worse  by  recurrent  dysentery. 

Nervous  System. — The  nervous  system  shows  disturbances  apparently 


DYSENTERY 


683 


associated  with  amebic  dysentery,  thus  some  forms  of  neuritis  and  neurosis. 
Sciatica  is  particularly  excited  by  amebic  dysentery,  also  various  chronic 
types  of  nervous  disease  and  occasionally  acute  chorea  may  occur. 

Albuminuria  is  common  in  chronic  amebic  dysentery  and  organic 
changes  may  exist  as  a  late  complication  or  one  of  its  after-effects. 

Among  other  occasional  complications  are  fibroid  degeneration  of  the 
heart,  terminal  pericarditis,  purpura,  gangrenous  ulcers  of  the  stomach, 
mastoid  abscess,  abscess  of  the  brain  (Kartulis),  pseudoparalysis  and 
gangrene  of  the  foot. 

Diagnosis. — In  amebic  dysentery  there  are  so  many  clinical  types 
that  the  diagnosis  is  by  no  means  easy,  and  can  only  he  made  absolutely 
by  microscopic  examination  of  the  feces. 

In  regions  where  the  disease  is  endemic  and  the  microscope  is  not 
available,  one  can  reasonably  infer  its  presence  by  the  most  valuable 
symptom,  to  which  I  have  already  alluded,  namely,  ''abdominal  soreness, 
which  is  increased  on  pressure,  and  extends  along  the  course  of  the  colon, 
especially  when  there  is  maximum  intensity  over  the  cecum  and  ascending 
colon." 

If  bowel  movements  are  present,  their  odor  and  the  appearance  of 
blood  are  of  chief  diagnostic  import.  Indigestion,  pain,  nausea,  and  other 
symptoms  are  not  as  important. 

Often  a  thickened  tender  colon  may  be  felt  on  palpation.  These 
symptoms  give  the  nearest  approach  to  diagnosis  without  microscopic  ex- 
amination of  the  feces.    Loss  of  weight  is  a  guide  to  the  infection. 

Musgrave  believes  that  the  presence  of  amebae  in  the  stools  in  tropical 
regions  should  be  considered  diagnostic  for  purposes  of  treatment. 

Amebiosis  should  be  treated,  even  if  other  complications  are  present. 

Prognosis. — The  disease  is  generally  milder  in  children  and  in  the 
natives  of  the  tropics.  The  course  is  shorter  and  the  mortality  higher 
among  the  aged.     Previous  good  health  is  a  favorable  factor. 

The  shorter  the  duration  of  the  disease  and  the  earlier  the  local  treatment, 
the  better  is  the  prognosis.     Early  emetin  treatment  shortens  it. 

The  higher  up  the  lesion,  the  greater  the  mortality  and  the  less  active 
the  clinical  symptoms  of  dysentery.  Infections  of  the  cecum  are  the  most 
serious. 

Under  proper  treatment  recovery  is  the  rule  in  young  and  welF-nour- 
ished  adults  if  the  disease  is  not  of  long  duration.  The  early  diagnosis 
and  treatment  are  the  important  features,  as  otherwise  the  apparently 
mild  cases  may  assume  a  dangerous  character.  Tendency  to  relapse  or 
chronicity  are  characteristics.  Abscess  of  the  liver  is  a  serious  complica- 
tion. 

After-efifects. — Constitutional  disturbances,  the  result  of  wasting  and 
of  lowered  resistance,  may  occur. 

Sprue  is  held  by  Musgrave  to  be  a  symptom-complex  and  not  a  distinct 
disease  and  to  arise  in  a  variety  of  wasting  diseases,  particularly  in  those 
attacking  the  gastro-intestinal  tract.  It  is  fairly  common  in  the  Philip- 
pines and  believed  to  develop  in  those  cases  of  amebiosis  particularly 
complicated  by  disturbances  of  the  stomach  and  small  intestines.  The 
'MUnch.  Med.  VVoch.,  Mar.  3,  1914. 


684  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

walls  of  the  intestines  are  enlarged,  thinned,  with  an  atrophied,  cystic  and 
often  papilloid  condition  of  the  mucosa  of  the  entire  gastro-intestinal  tract, 
and  a  relaxation  and  partial  destruction  of  the  muscular  bands  of  the  bowel, 
which  leave  it  elongated,  enlarged  in  diameter  and  without  its  natural 
folds,  or  rugae.  Change  of  climate  is  the  chief  requisite  for  these  cases. 
Leonard  Rogers  has  cured  two  cases  by  the  subcutaneous  injection  of  emetin 
and  the  use  of  autogenous  streptococci  vaccines  from  the  mouth.  Chronic 
gastro-enteritis  may  also  follow  dysentery,  and  abdominal  pain  and  sore- 
ness may  persist  for  years,  particularly  if  recurrences  have  taken  place. 
They  are  due  to  chronic  adhesive  peritonitis  and  the  symptoms  vary  with 
the  character  and  location  of  the  lesions.  They  may  resemble  a  chronic 
appendicitis  due  to  cecal  adhesions.  Pains  in  the  region  of  the  stomach, 
liver,  spleen,  ovaries  and  other  locations  occur.  There  may  be  general 
abdominal  soreness,  increased  in  the  erect  posture  and  relieved  when 
lying  down.  The  reverse,  however,  has  been  seen.  These  pains  may 
continue  for  years  or  they  may  recur  particularly  after  exposure  to  cold, 
or  after  violent  exercise.  Proper  exercise,  massage  and  belts,  bandages, 
or  corsets  of  correct  type  (particularly  if  there  is  splachnoptosis)  may 
improve  the  symptoms.  Mechanical  support  will  often  prevent  the  drag- 
ging down  pains  from  adhesions,  when  the  patient  is  erect.  Various 
types  of  nervous  disease,  chronic  rheumatism,  disturbances  of  the  genito- 
urinary system  such  as  the  kidneys  and  bladder,  skin,  etc.,  may  also  be 
among  the  after-efifects. 

Treatment. — Medical. — The  disease  is  contracted  probably  in  the 
same  way  as  typhoid  fever,  and  the  same  prophylactic  measures  should  be 
used.  Infection  through  the  drinking-water  is  undoubtedly  the  chief 
method. 

Musgrave  holds  that  the  best  rule  to  observe  in  countries  where  the 
disease  is  endemic  is  to  "take  nothing  into  the  gastro-intestinal  tract 
which  has  not  been  sterilized."  He  has  found  the  amebae  in  the  drinking- 
water;  on  dishes  washed  in  tap- water;  in  the  soil  from  contamination;  on 
the  surface  of  uncooked  vegetables,  such  as  lettuce;  on  raw  fruits;  from 
hand  contamination;  and  in  ice-cream,  water-ices,  and  milk. 

Prophylaxis,  when  the  disease  is  endemic  or  during  epidemics,  is  very 
important. 

Air  drinking-water  should  be  boiled,  and  dishes  should  be  washed  in 
boiled  water,  also  the  hands. 

Raw  fruits  and  vegetables  should  first  be  placed  on  ice,  and  then  have 
scalding  water  poured  over  them,  which  kills  the  amebae.  Ice-cream  and 
water-ices  should  not  be  taken. 

The  vaginal  douche  and,  especially,  rectal  enemata  from  tap-water 
should  be  avoided. 

The  stools  should  be  disinfected  in  carbolic  acid  (i  :  20)  or  in  bichlorid 
of  mercury  (i  :iooo),  and  the  same  precautions  taken  with  linen — soaked 
in  carbolic  acid  (i  :  20)  and  boiled. 

Care  of  the  hands  and  the  prevention  of  fly  infection  (by  screens)  are 
necessary. 

We  have  already  noted  that  mixed  infection  with  the  Bacillus  dysen- 
teriae  (Shiga)  may  be  present. 


DYSENTERY 


685 


The  acid  of  the  stomach  lessens  the  chance  of  infection,  and  acid  mixtures 
may  be  given,  such  as  dilute  hydrochloric  acid. 

In  acute  dysentery  the  patient  should  be  put  to  bed  and  placed  on  a 
liquid  diet:  barley-water,  rice-water,  bouillon,  broths,  gruels,  white  of  raw 
egg,  tea,  also  peptonized  milk  diluted  with  lime-water  (at  least  25  per 
cent,  or  more),  or  peptonized  and  diluted,  or  equal  parts  of  milk  and 
barley-water.  With  some  sour  milks  agree,  as  koumiss,  etc.  Turnip-top 
puree  has  been  advocated  as  of  value. 

Somatose  and  tropon  are  of  service  as  adjuncts.  Personally,  I  prefer 
milk-free  diet  and  only  the  strained  broths,  gruels,  etc.,  and  10  per  cent, 
gelatin  solution  flavored  with  vanilla,  4  to  6  ounces  (125-185  c.c).  Give 
nourishment  in  divided  doses  (2  quarts  daily)  and  a  large  amount  of  acidu- 
lated water.  If  the  temperature  is  over  103 °F.,  only  water  is  given  until 
defervescence  to  that  point.  Later  the  diet  can  be  increased  (see  author's 
diet  in  typhoid  fever). 

Hot  applications  or  poultices  should  be  employed  over  the  abdomen 
for  the  relief  of  pain  or  colic. 

Internal  Medication. — Musgrave  and  Osier  both  object  to  the  use  of 
bismuth  preparations  for  the  diarrhea,  on  the  ground  that  they  coat  the 
ulcers  and  interfere  with  their  local  treatment.  I  believe  this  probably 
to  be  true  as  regards  bismuth  subnitrate  or  subcarbonate,  which  would  be 
required  in  large  doses.  I  have  occasionally  employed  bismuth  subgallate, 
5  to  10  grains  (0.3-0.6)  t.i.d.,  in  combination  with  other  remedies,  appar- 
ently with  benefit. 

On  the  other  hand,  I  have  seen  at  times  that,  in  spite  of  all  treatment, 
too  frequent  movements  continue  either  in  the  acute  or  chronic  cases. 
In  such  event  I  have  employed  bismuth  subnitrate,  as  much  as  90  to  120 
grains  (6.0-8.0)  in  divided  doses  in  twenty-four  hours,  with  good  results. 
This  is  preferable  to  the  use  of  opiates,  and  I  only  employ  it  to  avoid  such. 
I  have  never  had  poisoning  from  large  doses  of  bismuth  subnitrate.  It 
would  seem  a  more  likely  occurrence  in  children. 

At  the  Ancon  Hospital,  Decks  and  Shaw  employ  chiefly  the  subnitrate 
of  bismuth  treatment,  i  to  i^  drams  (4.0-6.0),  by  measurement,  or  3 
drams  (12,0),  by  weight,  stirred  in  a  glass  of  water,  every  three  hours  until 
the  patient  improves,  which  may  be  from  three  to  fifteen  days.  Normal 
saline,  or  plain  water  irrigation  of  the  bowels  are  added.  Rest  in  bed  and 
an  absolute  milk-diet  are  enjoined.  An  occasional  dose  of  morphin  and 
atropin  may  be  required  to  relieve  tenesmus.  They  claim  fewer  fatalities 
by  this  method  than  by  other  courses  of  treatment.  Finally,  if  improve- 
ment does  not  follow  this  treatment,  and  the  acute  symptoms  are  severe 
and  toxic,  they  recommend  surgical  interference  (appendicostomy  or 
cecostomy),  as  advocated  by  Herrick.  The  latter  suggests  this  treatment 
for  the  following  conditions:  First,  appendicostomy  in  chronic  cases; 
second,  appendicostomy  or,  preferably,  cecostomy  in  acute  fulminating 
and  toxic  cases.  By  means  of  cecostomy,  especially  through  the  tempo- 
rary artificial  anus,  rest  is  given  to  the  diseased  bowel,  and  it  also  can  be 
kept  irrigated.  For  the  literature,  the  reader  is  referred  to  the  Medical 
Record,  Nov.  13,  1909.     The  writer  hardly  advocates  an  artificial  anus 


686  DISEASES    OF    THE    STOMACH   AND    INTESTINES 

in  acute  cases,  and  doubts  the  advisability  of  the  bismuth  treatment, 
except  as  previously  noted. 

In  the  initial  stage  the  patient  should  be  given  magnesium  or  sodium 
sulphate,  i  to  2  drams  (4.0-8.0),  one  or  two  doses,  so  as  to  thoroughly 
cleanse  the  bowels.  Calomel,  5  grains  (0.3),  may  be  given,  or  a  single 
dose  of  castor  oil,  i}i  ounces  (45.0). 

In  young  persons  these  remedies  should  be  administered  in  smaller 
doses. 

Ipecac  Treatment. — Some  recommend  20  minims  (1.18)  of  laudanum, 
followed  in  half  an  hour  by  20  to  30  grains  (1.3-2.0)  of  pulv.  ipecac,  after 
the  saline  treatment.  Though  given  thus  to  prevent  vomiting  it  is  not 
always  successful  in  this  regard. 

Brem  and  Zeiler^  report  excellent  results  at  the  Colon  Hospital  in  the 
treatment  of  intestinal  amebiosis  from  the  use  of  ipecac  pills  freshly 
coated  with,  fused  salol  }4q  inch  thick.  By  this  means  the  ipecac  passes 
through  the  stomach  unattacked  by  the  gastric  juice;  vomiting  is  pre- 
vented and  no  opiate  is  necessary.  Simon^  has  used  a  salol  coating  % 
inch  thick,  but  many  pills  passed  through  the  intestines  undissolved. 
They  found  the  best  method  usually  was  to  begin  with  60  to  80  grains  at 
bedtime,  8  to  9  P.  M.,  decrease  the  dose  by  5  grains  daily  until  a  dose  of 
10  grains  (in  all)  is  reached,  and  then,  as  a  rule,  stop.  Occasionally  rapid 
cures  may  be  effected  by  giving  40  grains  t.i.d.  These  writers  observed 
that  milk  curds  or  solid  food  delayed  the  passage  of  the  pills  until  the  salol 
coat  was  corroded,  and  vomiting  ensued.  They,  therefore,  direct  that 
no  solid  food  or  milk  should  be  given  for  at  least  six  hours  previous  to  the 
ipecac,  and  no  liquids  for  three  hours  previous.  No  opiate  is  necessary. 
Have  the  patient  lie  on  the  right  side  to  aid  passage  of  pills  from  the  stom- 
ach. The  patient  should  remain  in  bed  and  the  general  diet  should  be 
liquid.  Enemata  of  normal  saline  solution,  quinin,  thymol,  and  thymol 
and  quinin  combined,  i :  500  to  i :  1000  each,  are  useful. 

Dock^  has  reported  excellent  results  from  the  ipecac  treatment. 
Leonard  Rogers^  reports  favorable  results  in  Calcutta  in  the  prevention 
of  tropical  abscess  (amebic)  of  the  liver  by  the  treatment  of  the  presup- 
purative  stage  with  ipecac.  He  suggests  the  use  of  capsules  of  ipecac, 
keratin  coated.  A  shellac  coating  can  also  be  employed  (author),  while 
Sandwith  advocates  capsules  of  animal  membrane.  Anders^  starts  the 
treatment  with  calomel  (several  doses),  and  then  administers  magnesium 
sulphate,  i  dram  (4.0)  every  third  hour,  until  all  hardened  fecal  masses 
are  removed.  Saline  laxatives,  however,  should  not  be  continued  after 
the  dysenteric  have  been  converted  into  diarrheal  dejecta.  Anders  ad- 
vocates also  the  use  of  ipecac  administered  by  salol-covered  pills  in  the 
earlier  stages  of  the  disease,  not  less  than  30  grains  (2.0)  of  ipecac  on  the 
first  day,  and  diminishing  the  dose  daily  by  5  grains  (0.3),  so  that  by  the 
sixth  day  only  5  grains  (0.3)  are  administered,  and  for  a  week  or  ten  days 
this  nightly  dose  of  5  grains  (0.3)  should  be  continued.     He  adds  to  the 

^  Amer.  Jour.  Med.  Sci.,  Nov.,  19 10. 

^  Jour.  Amer.  Med.  Assoc,  1909,  liii,  1526. 

^  N.  Y.  Med.  Jour.,  July  10,  1909;  ibid.,  Dec.  4,  1909. 

*  Therap.  Gaz.,  June  15,  1909. 

*  Jour.  Amer.  Med.  Assoc,  Feb.  12,  1910. 


DYSENTERY  687 

treatment  daily  high  enemata  of  quinin  solution,  i  :  5000,  gradually  in- 
creasing the  strength  to  i  :  1000.  In  obstinate  chronic  cases  appendicos- 
tomy  with  bowel  irrigation  is  advocated.  H.  G.  Beck^  administers  the 
ipecac  suspended  in  mucilage  of  acacia  or  macerated  in  warm  water 
through  Einhorn's  duodenal  tube  by  means  of  a  syringe.  He  claims  to 
thus  avoid  vomiting.  Burroughs  and  Wellcome  have  recently  intro- 
duced a  gr.  V  ipecac  tabloid  deprived  of  its  emetic  principles.  Dose 
4  to  6  tablets  t.i.d.  dissolved  in  water. 

A  great  improvement  in  therapeutics  is  the  use  of  emetin.  It  has  a 
specific  action  on  the  amoeba  dysenteries.  Leonard  Rogers^  reports  that  the 
amceba  dysenteriae  is  immediately  killed  by  a  i  in  10,000  solution  of  emetin 
and  after  a  few  minutes  was  rendered  inert  and  apparently  killed  by  a 
weak  solution  of  i  in  100,000.  He  advocates  the  use  of  emetin  by  hypo- 
dermic. He  secured  excellent  results  in  the  most  serious  cases,  following 
the  use  of  emetin  hydrobromid  hypodermically.^  He  estimates  gr.  i 
of  emetin  an  equivalent  of  90  grains  of  ipecac.  Improvement  usually 
occurred  in  twenty-four  to  forty-eight  hours,  and  in  three  to  five  days  con- 
valescence apparently  began.  The  preparation  comes  in  ampoules  or  in  }4 
grain  tablets.  Usually  gr.  }^  can  be  given  by  hypodermic  twice  or  three 
times  the  first  day.  Subsequently  i\i\.0  2  grains  in  divided  doses,  by  hypo- 
dermic the  second  day,  depending  on  the  severity  of  the  case  and  a  grain  by 
hypodermic  on  the  third  and  fourth  day.  For  a  child  of  seven,  }i  grain 
t.i.d.  has  been  administered.  The  injection  of  emetin  cured  acute  hepati- 
tis and  aborted  a  commencing  amebic  abscess  of  the  liver.  Liver  abscesses 
have  been  cured  by  aspiration  and  then  injecting  through  the  tube  2  ounces 
of  sterile  saline  solution  in  which  ly^  grains  of  emetin  were  dissolved.  Hy- 
podermics of  emetin  totaling  %  to  i  grain  daily,  were  also  administered. 
Success  was  also  secured  in  amebic  abscess  of  the  spleen  by  similar  treat- 
ment. Emetin  treatment  has  also  rapidly  cured  cases  of  chronic  amebic 
dysentery.  Burroughs  and  Wellcome  and  Parke  Davis  supply  tablets 
and  ampoules.  Emetin  hydrochlorid  is  somewhat  more  soluble  than  the 
hydrobromate.  Rogers  holds  that  emetin  affects  the  amebic  type  of 
dysentery  favorably,  and  not  the  bacillary  and  other  types  materially; 
and  hence  favorable  results  from  its  use  diagnose  the  amebic  type  when 
pathologic  examination  is  impossible. 

Though  patients  may  be  clinically  cured  of  amebic  dysentery  the 
Entamoeba  histolytica  may  be  found  subsequently  for  two  years  or  more 
without  development  of  symptoms.  They  constitute  a  menace  as  "car- 
riers." Enteroclysis  with  silver  nitrate,  quinin  or  other  remedies,  such 
as  acetozone,  etc.,  would  be  of  value,  also  emetin.  Emetin  has  also  been 
used  successfully  by  mouth.  It  can  be  so  administered,  ^i  grain  t.i.d. 
in  keratin-coated  pills,  or  capsules  shellaced. 

A  standardized  preparation  of  emetin,  from  a  reliable  source  should  be 
employed.  Two  fatal  cases  have  been  reported,  one  of  acidosis  and 
acute  nephritis  following  its  use.  Persistent  diarrhea  may  also  result, 
after  apparent  cure  of  the  dysentery. 

*  Jour.  A.  M.  A.,  Dec.  14,  191 2. 

^  Brit.  Med.  Jour.,  June,  22,  191 2. 

*Ind.  Med.  Gazette,  1912,  xlvii,  421,  Aug.  24,  1912. 


688  DISEASES   OF   THE    STOMACH    AND   INTESTINES 

Occasionally,  salol,  3  grains  (0.194),  with  guaiacol  carbonate,  3  grains 
(0.194),  and  I  grain  (0.065)  o^  pulverized  ipecac,  given  several  (three  or 
four)  times  a  day,  with  small  doses  of  Dover's  powder,  2  to  3  grains 
(0.13-0. 194),  have  proved  of  service  according  to  some  reports.  Kho-sam 
(Brucea  Sumatra  or  Brucea  antidysenterica),  in  i-grain  pills  three  or  four 
times  daily,  has  been  suggested  in  place  of  ipecac  by  Lemoine^  and  Schnei- 
der.^ Salvarsan  and  neosalvarsan  have  been  advocated  but  I  doubt  their 
value. 

Chaparro  amargosa  in  the  form  of  fluidextract,  5i"~5iu  t.i.d.  before 
meals,  or  as  an  infusion,  5vi-viii  t.i.d.  before  meals,  and  at  bedtime  and 
in  addition  rectal  injections,  500  to  2000  c.c.  of  infusion,  have  been  recom- 
mended by  Nixon  (Journal  A.  M.  A.,  May  16,  1914).  This  remedy  has 
been  employed  in  Mexico  for  many  years  and  is  said  to  be  destructive  to 
the  ameba. 

Strong  has  reported  good  results  in  some  cases  by  giving  internally 
acetozone  (i  :5ooo  or  i  :3ooo)  in  carbonated  water,  i  to  2  liters  (quarts) 
in  twenty-four  hours  in  divided  doses. 

I  have  employed  i  liter  (quart)  of  acetozone  (i  :  1000),  given  in  divided 
doses  by  mouth  during  the  day  with  good  results.  Just  before  administer- 
ing, each  dose  can  be  flavored  with  orange-juice  to  make  it  more  palatable. 

Among  valuable  astringent  remedies  are: 

Salicylate  of  guaiacol  (guaiacol-salol),  5  to  10  grains  (0.3-0.6);  tannal- 
bin,  10  grains  (0.6) ;  tannigen,  10  grains  (0.6) ;  or  tannoguaiaform,  tannopin, 
and  tannocol,  given  in  doses  of  5  to  10  grains  (0.3-0.6)  three  or  four  times 
a  day. 

Hydrochloric  acid  with  pepsin  or  alone,  or  nitromuriatic  acid  are  of 
value  being  destructive  to  nonencysted  amebse.  Musgrave  recommends 
hydrochloric  acid  to  immunize  chances  of  infection.     Thus: 

R.  Acidi  hydrochlor.  dil.   1  .._...., 

^    ry  \.-     .      •     ,  > aa   3"J  (12.0); 

Comp.  tinct.  cinchona  j  «^   j  \        /  > 

Aq.  destil q.  s.   5iv  (125.0). — M. 

Sig. —  3j  to  ij  (4.0-8.0)  in  water  t.i.d.  before  food. 

Vomiting  should  be  treated  by  the  methods  described  under  Acute 
Gastritis.  Small  doses  of  Dover's  powder  may  be  required  for  persistent 
diarrhea. 

Local  Treatment. — This  is  of  extreme  importance,  not  only  in  the  acute, 
but  also  in  the  latent  and  chronic  cases. 

Extensive  researches  were  conducted  by  J.  B.  Thomas,  reported  in 
Bulletin  32,  Bureau  Government  Laboratory,  Manila,  who  found  the 
following  solutions  destructive  to  amebae  or  inhibiting  their  growth: 

Acetozone,  i  :  1000,  most  destructive  to  amebae,  and  alphozone, 
I  :  1000,  nearly  as  much  so. 

They  destroy  other  bacteria  as  well. 

Protargol  and  argyrol,  i  :5oo,  were  excellent  antiseptics.  Sulphate 
of  quinin,  1:500,  preferable  strength,  or  bisulph-quinin;  nitrate  silver, 
1:2000,  of  service;  thymol,  1:2500,  readily  destroys  amebae,  also  per- 
manganate of  potash,  I  :  2000,  is  useful. 

^  Bull.  Path.  Exot.,  Paris,  1908,  i,  72. 
« Ibid. 


DYSENTERY  689 

Hydrogen  peroxid  was  recommended  by  Harris  some  years  ago,  and 
I  have  used  it  successfully  for  some  time. 

Cold  water  (under  a  temperature  of  45°F.)  has  been  highly  advocated 
by  the  late  J,  P.  Tuttle  as  destructive  to  the  amebae,  and  also  removing 
them  from  the  bowel.  He  sometimes  employed  5  to  10  per  cent,  hydro- 
gen peroxid  in  this  injection,  and  placed  the  patients  in  the  knee-chest 
position  and  had  them  retain  the  injection  for  a  considerable  time  (one- 
half  hour). 

A  glass  irrigator,  attached  to  a  colon-tube,  with  the  opening  preferably 
at  the  end,  can  be  iemployed;  if  the  ulcers  extend  low  down  into  the  rectum 
or  there  is  extreme  tenesmus,  then  an  ordinary  rectal  tip. 

The  foot  of  the  bed  should  be  elevated  12  to  18  inches  and  the  patient 
placed  in  the  Sims  position,  or  the  hips  can  be  elevated  on  a  pan.  The 
patient's  position  should  be  changed,  and  he  should  be  moved  so  the  fluid 
will  gravitate  into  the  caput  coli  by  movements  described  as  "rotation 
method"  under  Enteroclysis. 

Musgrave  recommends  the  injection  of  at  least  2  to  3  liters  up  occa- 
sionally to  4  liters  (quarts)  in  women,  which  should  be  retained  five  to 
fifteen  minutes,  preferably  the  latter.  At  the  commencement,  if  there  is 
much  irritation,  often  a  smaller  quantity  must  be  used.  He  recognizes  the 
f  utiUty  of  attempting  to  pass  the  colon  tube  and  now  employs  an  ordinarily 
large-size  male  soft  rubber  catheter  to  which  is  attached  an  irrigating 
jar,  preferably  one  of  glass.  Brandy  25  to  30  c.c.  can  be  given  by  mouth 
before  the  injection.  Enemas  should  not  be  given  during  digestion,  as  the 
reversed  peristalsis  set  up  by  the  injection  may  aggravate  stomach 
symptoms. 

The  knee-chest  position  is  excellent  in  the  latent  or  chronic  cases,  but 
I  would  not  advise  it  in  acute  conditions. 

If  there  is  much  irritation,  one  can  precede  the  antiseptic  injection 
one-half  hour  by  a  small  enema  of  normal  saline  solution — 2  ounces 
(60.0)  containing  }-i  grain  (0.016)  of  morphin — or  with  tincture  of  bella- 
donna, 10  minims  (0,592),  alone  or  together. 

This  should  only  be  done  once  or  twice  in  the  first  twenty-four  hours 
and  not  repeated. 

Musgrave  has  suggested  taking  advantage  of  the  action  of  reversed 
peristalsis  by  giving  occasionally  a  preliminary  enema  of  a  7  to  8  per 
cent,  salt  solution,  about  i  pint  (500  c.c),  containing  K  grain  (0.016)  of 
morphin,  one-half  hour  before  the  antiseptic  injection.  Musgrave  has 
found  thymol  very  efficient  and  as  it  is  difficult  to  dissolve  it  in  water  he 
recommends 

!^.     Thymol gm.  25. 

Alcohol (95  per  cent.) 

Glycerin aa  250  c.c. — M. 

Sig. — Add  10  c.c.  of  above  to  each  liter  of  water  used  in  enema.  This  gives 
approximately  a  strength  of  i  :  2000  quite  an  efficient  solution  as  it  is  destructive  to 
the  amebae  at  i  :  10,000  strength.  He  alternates  at  times  with  quinin  1  :  1000  to  i  :  500 
or  with  silver  nitrate  o.i  to  i  per  cent,  in  distilled  water.  The  nitrate  of  silver  is 
preferable  I  believe  in  chronic  cases. 

He  at  times  employs  acetozone  (i  :5ooo  to  i  :3ooo),  combined  with 
quinin  (i  :iooo  to  i  :50o),  or  gives  the  injections  alternately,  employing 

44 


690  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

one  to  five  enemata  every  twenty-four  hours,  according  to  ithe  severity 
of  the  case.     Bisulphate  of  quinin  is  more  soluble. 

Alphozone,  same  strength,  or  hydrogen  peroxid  (i  :  10)  can  be 
substituted. 

We  must  remember  that  quinin  affects  some  cases  badly,  causing 
gastric  symptoms,  vomiting,  and  headache.  It  must  be  omitted  or  weaker 
solutions  given  to  such  patients. 

Quinin  is  much  more  efficacious  in  the  strong  solutions  (1:1000  to 
even  1:500).  The  usual  solutions  suggested  are  much  too  weak.  One 
can  take  advantage  at  the  same  time  of  the  cold  injections,  as  suggested 
by  Tuttle,  unless  the  patient  have  an  idiosyncrasy  to  cold,  or  renal 
complications  are  present.  In  such  event  a  hot  injection  at  120*^.  is 
of  service. 

Author's  Method. — In  conclusion  the  author  now  employs  the  hypo- 
dermic use  of  emetin  gr.  }4  t.i.d,  and  administers  acetozone  i  :  1000,  i 
quart  daily  in  divided  dose  by  mouth.  The  patient  should  also  receive 
hydrochloric  acid  mixture.  The  local  treatment  is  also  important.  The 
writer  prefers  the  following  local  treatment. 

An  excellent  method  is  to  alternate,  giving  an  enema  of  acetozone 
(1:1000),  and  the  next  enema  of  quinin  (1:1000  to  1:500),  cold,  at 
45°  to  40°F. 

If  the  quinin  disagrees,  then  alternate  the  acetozone  or  alphozone 
with  thymol  (1:2500),  or  protargol  or  argyrol  (1:500).  The  silver 
nitrate  is  at  times  found  irritating  in  the  acute  cases. 

Permanganate  of  potash  (1:2000)  is  also  of  service,  or  hydrogen 
peroxid,  4  ounces  (125.0  c.c.)  to  i  liter  (quart). 

Emetin  is  a  specific  and  the  local  treatment  helps  check  the  lesions  and 
prevent  liver  abscess.  For  prevention  of  the  latter  emetin  is  of  great 
value  given  by  hypodermic.  In  the  latent  cases,  the  bowels  should  be 
opened  freely  with  magnesium  sulphate  and  daily  injections  of  quinin 
and  acetozone  given.  In  cases  of  marked  tenesmus,  where  the  large 
or  even  small  injections  cannot  be  retained,  recurrent  irrigations  with 
the  antiseptic  solutions,  i  or  2  gallons — i  pint  (500  c.c.)  being  kept  in 
the  bowels,  with  marked  elevation  of  the  bed  and  the  solution  of  one-half 
strength — are  of  great  service.  Emetin  should  also  be  given  in  the  latent 
cases.    Local,  or  general  peritonitis  ^require  surgery. 

Chronic  Dysentery. — In  the  chronic  cases  the  diet  should  be  quite  liberal, 
but  indigestible  and  rich  food  should  be  avoided.  Mashed  potatoes, 
boiled  rice,  and  constipating  food  are  often  indicated  in  the  diarrheal 
cases,  and  the  avoidance  of  fruits  and  green  vegetables.  Milk,  eggs 
(raw),  the  sour  milks,  and  fats  are  of  value.  Judgment  must  be  used  in 
each  case  as  to  what  will  agree,  whether  liquid,  semisolid,  soUd  food,  or 
combinations.  The  iron  preparations  are  often  indicated.  The  tannic 
acid  preparations,  as  suggested  in  the  acute  cases,  should  be  employed. 
Occasionally  large  doses  of  bismuth  subnitrate  are  necessary.  Quinin 
and  acetozone  injections  should  always  be  employed;  and  nitrate  of  silver 
(1:3000  to  1:2000)  or  protargol,  or  argyrol  i  :  2500  are  of  value,  used 
once  or  twice  a  week  to  heal  the  ulcers.  Change  of  climate  is  useful. 
1  Proctoclysis  is  of  value  for  sepsis,  or  thirst. , 


DYSENTERY  69 1 

Emetin  gr.  ]4  t.i.d.  by  hypodermic  should  be  given  as  in  the  acute 
cases  and  also  acetozone  by  mouth. 

In  all  cases  of  fever,  sponging  (alcohol)  is  the  best  method  of  treat- 
ment. I  deprecate  the  use  of  antipyretics.  If  heart  stimulants  are 
required,  small  doses  of  strychnin,  caffein,  and  spartein,  or  camphorated 
oil  by  hypodermic  are  indicated. 

I  have,  moreover,  a  suggestion  which  I  believe  may  prove  of  value. 
Piffard  and  Tousey  have  demonstrated  that  Morton's  claims  regarding 
the  production  of  internal  fluorescence  by  the  x-rays  after  the  adminis- 
tration of  small  doses  of  fluorescein  or  quinin  are  fallacious.  However, 
the  use  of  yi  grain  (0.016)  to  about  grs.  2  fluorescein  in  6  ounces  (200  c.c.) 
of  water,  and  placing  the  patient  in  the  full  electric-light  bath  for  fifteen 
minutes  or  more,  I  believe,  might  prove  of  service  in  latent,  chronic,  or 
even  in  acute  dysentery.  There  is  great  heat  penetration  from  light  bath, 
as  has  been  demonstrated  in  rheumatic  and  other  conditions,  and  neces- 
sarily a  certain  penetration  of  light  rays.  The  heat,  light,  and  fluorescence 
are  destructive  to  amebae.  The  fluorescein  solution  should  be  given  by 
high  enema;  soda  bicarbonate,  15  grains,  should  be  added  before  injection, 
and  water  q.  s.  i  quart  (liter).  Musgrave  reports  to  me  the  disappear- 
ance of  filaria  after  the  administration  of  fluorescein  and  the  use  of  light. 
He  has  demonstrated  that  violet  light,  a;-ray  light,  and  fluorescence  in- 
hibit amebic  action. 

Carbonic  Acid  Gas  for  Tenesmus. — Rose  has  shown  that  the  injection 
of  CO2  into  the  rectum  will  relieve  tenesmus.  It  is  worthy  of  use  as  an 
adjunct  and  can  be  given  by  his  bottle. 

Intestinal  hemorrhage  from  dysenteric  ulcers  should  be  treated  by 
high  injections  of  10  per  cent,  gelatin  or,  preferably,  Tremoli&re's  solution, 
or,  rather,  a  modification: 

Tremolitre. — Gelatin,  5  per  cent,  solution,  containing  calcium  chlorid, 
2  per  cent. 

Tremolitre  (^Modified). — Calcium  lactate,  20  grains  (1.3);  gelatin  (10 
per  cent.),  8  ounces  (500  c.c). 

Hot  (i2o°F.)  or  cold  (40°F.)  astringent  injections — i  dram  (4.0)  alum 
or  tannic  acid  to  i  pint  (500  c.c.)  of  water — may  be  required.  Avoid  cold 
if  there  is  shock. 

Morphin,  J^  to  K  grain  (0.008-0.016),  by  hypodermic  at  once,  ernutin, 
5  minims  (0.296),  hypodermically,  or  fluidextract  of  ergot,  i  dram  (4.0), 
internally;  ice-bag  locally;  calcium  chlorid  or  lactate,  10  grains  (0.6), 
by  mouth  every  three  hours,  gelatin  solution^  (5  per  cent.)  may  also  be 
taken  by  mouth.  Hypodermoclysis  may  be  required  if  there  is  marked 
shock,  or  even  infusion.  Horse  serum  or  human  serum  by  hypodermic 
may  be  required  in  severe  cases. 

Surgical  Treatment. — In  cases  of  chronic  dysentery  of  long  duration 
which  do  not  respond  to  medical  treatment,  or  in  such  cases  with  repeated 
acute  exacerbations,  surgical  procedure  is  indicated.  This  is  true  of 
either  the  amebic  or  bacillary  type  of  dysentery. 

Appendicoslomy. — This  operation  was  first  suggested  by  Weir.  It 
consists  in  suture  of  the  appendix  to  the  abdominal  wall  and  skin,  and 
*  The  gelatin  solution  should  be  given  in  3 1  doses  every  3  hours. 


692  .  DISEASES    OF   THE    STOMACH    AND    INTESTINES 

removal  of  its  apex.  Subsequent  irrigations  of  the  large  intestine  are 
carried  out  by  means  of  a  small  tube  or  catheter,  which  is  inserted  through 
the  lumen  of  the  appendix. 

Cecostomy. — An  incision  is  made  over  the  cecum  and  the  latter  brought 
into  the  abdominal  wound.  The  cecum  is  incised  and  sutured  to  the 
abdominal  wall.  A  catheter  or  drainage-tube  is  then  inserted  for  the 
purpose  of  irrigation  of  the  colon.  Gibson  has  devised  a  valve  operation, 
separating  the  abdominal  muscles  in  a  special  manner,  so  as  to  prevent 
leakage  and  ultimately  secure  a  more  ready  healing.  Cecostomy  is 
indicated  when  the  appendix  is  diseased  or  in  an  abnormal  position,  so 
that  appendicostomy  is  impossible. 

S.  G.  Gant^s  Modified  Cecostomy. — Gant^  makes  his  incision  over  the 
cecum  nearer  the  ileocecal  junction.  After  opening  the  cecum  and 
suturing  it  to  the  abdominal  wall  by  means  of  a  special  director,  he  in- 
serts a  drainage-tube  or  catheter  through  the  ileocecal  valve  into  the 
ileum.  A  second  tube  is  inserted  into  the  cecum.  In  cases  where  ulcera- 
tion of  the  ileum  is  present,  it  is  thus  possible  to  irrigate  both  ileum  and 
colon.     With  amebic  dysentery  the  ileum  is  rarely  involved. 

Excellent  results  have  been  reported  from  these  methods. 

Abscess  of  the  Liver. — These  should  be  opened  and  drained. 

Rogers^  states  that  in  the  presuppurative  stage  of  amebic  abscess  of 
the  liver  there  is  an  exacerbation  of  temperature,  with  usually,  but  some- 
times without,  pain  in  the  liver  region,  and  leukocytosis  is  present.  He 
recommends  ipecac  as  a  preventive  of  suppuration.  With  suppuration 
there  is  increased  density  of  the  liver  shadow  to  the  .r-rays,  local  swelling, 
and  edema  with  increasing  leukocytosis.  Rogers  holds  that  86  per  cent, 
of  these  abscesses  are  sterile  and  are  infected  by  other  bacteria  by  the 
open  operation.  He  recommends  repeated  aspirations  of  the  abscess- 
cavity  with  the  injection  of  quinin  solution  without  drainage.  If  this 
method  fails,  add  sterile  siphon  drainage.  Ipecac  is  also  given.  As- 
piration, with  the  injection  of  gr.  i  emetine  in  5ii  saline  solution  into 
the  abscess-cavity,  together  with  the  hypodermic  administration  of 
emetin  gr.  i  daily,  give  the  best  results. 

BACILLARY  DYSENTERY 

Definition. — A  form  of  colitis,  frequently  an  ilecolitis,  usually  of  an 
acute  type;  occurring  sporadically  and  in  severe  epidemics;  attacking 
children  as  well  as  adults,  and  characterized  by  pain,  tenesmus,  and  the 
frequent  passage  of  blood  and  mucus;  the  result  of  infection  by  a  specific 
bacillus,  of  which  there  are  various  strains. 

Etiology. — Owing  to  improvement  in  sanitary  conditions,  bacillary 
dysentery  is  less  frequent.  This  is  the  type  which  has  proved  such  a 
scourge,  as  epidemics  in  crowded  asylums,  institutions,  and  camps.  It 
is  one  of  the  great  camp  diseases,  and  I  have  already  referred  to  the  fact 
that  Woodward  collected  259,071  acute  cases  during  the  Civil  War.  The 
disease  prevails  in  the  Philippines,  Porto  Rico,  Cuba,  and  in  South 
Africa.     In  Japan  a  fatal  type  has  prevailed,  especially  in  summer  and 

^  N.  Y.  Med.  Jour.,  Aug.  15,  1908. 
*  Philippine  Jour,  of  Sci.,  July,  1910. 


DYSENTERY  693 

autumn,  having  a  mortality  of  over  25  per  cent.  In  1899  there  were 
125,489  cases  with  26,709  deaths,  collected  by  Eldridge.  Most  of  the 
severe  epidemics  in  the  tropics  are  of  the  bacillary  type,  and  the  same 
form  prevails  in  the  temperate  climates. 

Bacillus  DysentericB. — In  1892  Ogata,  during  an  epidemic  of  dysentery 
in  Japan,  isolated  fine  bacilli  which,  when  introduced  by  the  mouth  or 
rectum,  produced  ulceration  in  the  intestines  of  cats.  In  1897,  during  a 
severe  epidemic,  Shiga  isolated  the  Bacillus  dysenteriae  and  described  its 
special  characteristics,  demonstrating  it  to  be  the  specific  cause  of  the 
disease.  Flexner  and  Barker  found  in  the  dysentery  in  the  Philippines 
an  identical  organism,  and  Strong,  Musgrave,  and  Craig  have  made  a 
careful  study  of  it. 

It  has  been  found  in  acute  dysentery  in  Porto  Rico.  Out  of  1238  cases 
of  dysentery  in  Manila,  Strong  and  Musgrave  report  71  of  the  bacillary 
type,  51  suspected  bacillary,  and  561  amebic. 

Kruse,  in  Germany,  has  isolated  an  identical  bacillus.  Vedd^r  and 
Duval  demonstrated  that  sporadic  cases  in  adults  in  Philadelphia,  and 
also  epidemics  in  the  Lancaster  County  Asylum,  Pennsylvania,  and  in 
the  Almshouse,  New  Haven,  were  due  to  the  Bacillus  dysenteriae.  Duval 
and  Bassett,  during  the  summer  of  1902  at  Mount  Wilson  Sanitarium,  first 
demonstrated  that  certain  forms  of  summer  diarrhea  in  infants  were  due 
to  Bacillus  dysenteriae,  and  under  Flexner's  direction  at  the  Rockefeller 
Institute  investigation  into  the  cause  of  infantile  diarrhea  in  New  York, 
Boston,  Philadelphia,  and  Baltimore,  showed  the  Bacillus  dysenteriae 
present  in  63  per  cent,  out  of  412  cases. 

Several  strains  of  this  bacillus  have  been  found,  and  the  Flexner- 
Harris  type  is  the  one  most  frequent  in  the  United  States.  These  strains 
have  been  determined  by  the  relative  agglutinative  power  of  immune 
serum  upon  the  bacilli  isolated,  and  also  by  the  action  of  the  bacilli  upon 
various  sugars.     Flexner  formerly  recognized  three  types: 

1.  "Shiga  type"  attacks  glucose,  without  action  on  other  sugars, 
including  mannite  and  lactose. 

2.  " Flexner-Harris  type"  attacks  glucose,  mannite,  and  dextrin,  not 
lactose. 

3.  "Bacillus"  (His  and  Russell)  attacks  glucose  and  mannite.  No 
action  on  dextrin  and  lactose.  His  now  recognizes  four  groups  based  on 
fermentative  characteristics,  and  Shiga  has  added  a  fifth,  intermediate 
between  the  acid  and  non-acid  bacilli.  Grolier^  states  that  no  less  than 
123  different  strains  of  dysentery  have  been  isolated,  differing  from  one 
another  widely.  In  some  cases  clinically  dysenteric,  it  may  be  impossible 
to  isolate  any  of  the  forms  because  they  are  soon  overgrown  by  the 
colon  group. 

The  lesions  produced  by  the  different  strains  are  identical.  The 
organism  agglutinates  with  the  blood-serum  of  cases  with  acute  dysentery, 
as  well  as  with  the  serum  of  immunized  animals.  The  Flexner-Harris 
type  agglutinates  in  dilutions  of  i  :  1000  to  i  :  1500. 

In  two  instances  the  organism  has  been  isolated  by  Duval  in  the  stools 
of  healthy  children.  In  dysenteric  stools  it  is  most  readily  isolated  from 
1  Deutsche  medizin.  Wochens.,  Oct.  i,  1914. 


694  DISEASES   OF  THE   STOMACH   AND   INTESTINES 

the  particles  of  mucus.  The  organism  has  not  yet  been  isolated  outside 
the  human  body,  but  the  beUef  is  that  it  is  probably  water-borne,  and  that 
the  same  prophylactic  measures  should  be  taken  as  in  typhoid  fever. 
Camp  epidemics  clearly  originate  in  this  way,  and  the  care  taken  by  the 
Japanese  in  regard  to  the  latrines  and  water-supply  practically  eliminated 
the  disease  during  their  recent  war. 

Bussow^  describes  a  small  epidemic  of  dysentery  in  a  hospital  ward  due 
to  the  cook  as  a  carrier.  Flexner  bacilU  were  recovered  from  the  stools. 
The  cook  was  suffering  from  diarrhea,  but  without  general  symptoms. 

Morbid  Anatomy. — In  acute  cases,  when  death  has  occurred  during 
the  first  week,  the  mucous  membrane  of  the  large  intestine  is  swollen, 
hyperemic,  of  a  deep  red  color,  and  presents  elevated  coarse  ridges  and 
folds.  There  are  ecchymotic  patches  scattered  throughout  the  swollen 
mucosa;  over  the  surface  there  is  usually  a  superficial  necrotic  layer, 
which  can  be  brushed  off  lightly  with  the  finger.  This  may  be  in  patches 
or  over  large  areas.  There  is  no  ulceration,  but  only  the  superficial  general 
necrosis  of  the  mucosa.  They  are,  in  effect,  superficial  erosions  which 
give  it  a  worm-eaten  appearance.  This  superficial  necrotic  layer  is,  in 
effect,  a  fine  pseudomembrane. 

The  solitary  follicles  are  swollen  and  red,  but  their  prominence  is 
obscured  in  the  involvement  of  the  mucosa. 

In  severe  cases  the  entire  coats  of  the  colon  may  be  stiff  and  thick, 
and  the  mucous  membrane  greatly  increased  in  thickness,  grayish-black 
in  color,  extensively  necrotic,  and  in  places  gangrenous.  The  submucosa 
is  often  enormously  thickened  and  edematous.  The  serous  surface  is 
often  deeply  injected,  and  the  vessels  of  the  mesentery,  especially  near 
the  sigmoid  and  rectum,  may  be  distended. 

The  ileum  for  lo  to  15  cm.  is  quite  frequently  involved  (which  is  rare 
in  amebic  dysentery),  having  a  deeply  hemorrhagic  mucosa  with  super- 
ficial necrosis.  Peyer's  patches  and  the  solitary  glands  may  be  moder- 
ately swollen.  The  specific  bacilli  and  various  cocci  are  abundant  in  the 
necrotic  mucous  membrane,  and  are  said  by  Strong  to  be  seen  in  all  the 
coats.     Streptococci  and  various  other  types  may  be  present. 

In  the  subacute  cases  there  is  less  thickening  of  the  intestinal  walls, 
there  is  less  necrosis,  the  solitary  follicles  are  more  swollen,  the  mucosa 
less  red,  there  are  superficial  erosions,  and  no  ulcers.  The  disease,  as 
suggested  by  the  complications,  is  evidently  characterized  by  a  more  or 
less  acute  general  toxemia,  starting  from  a  localized  process.  The  toxins 
of  dysentery  are  probably  excreted  by  the  bile  and  also  through  the  in- 
testinal mucosa,  thus  aiding  in  the  damage  to  the  intestines.  Probably 
the  toxins  are  responsible  for  cerebrospinal  lesions  (Herter). 

Sjrmptoms. — ^The  incubation  period  is  not  more  than  forty-eight  hours. 
The  onset  is  usually  sudden  and  characterized  by  fever,  pain  in  the  ab- 
domen, and  frequent  stools,  first  containing  mucus,  and  later  consisting 
chiefly  of  mucus  and  blood.  The  movements  increase  in  frequency  and 
are  associated  with  tenesmus,  which  becomes  very  marked.  The  move- 
ments may  occur  as  frequently  as  every  half-hour,  and  there  is  much 
straining.  The  tongue  is  coated  with  a  white  fur  and  there  is  excessive 
^Munchener  medizinische  Wochens.,  Dec.  27,1910. 


DYSENTERY  695 

thirst;  nausea  and  vomiting  may  occur.  The  abdomen  is  not  distended, 
but  there  may  be  tenderness,  especially  over  the  colon.  There  are 
cramp-like  pains  in  the  abdomen.  The  spleen  is  not  usually  enlarged. 
The  temperature  rises  to  103°  or  io4°F.  It  may  run  an  irregular  course 
and  rise  or  fall  before  death.  The  pulse  increases  in  rapidity  (100  to  120 
or  even  to  150)  and  becomes  rapid  and  feeble.  Urine  is  decreased  and 
may  contain  albumin.  Liver  is  not  enlarged  and  no  liver  abscess  occurs; 
moderate  leukocytosis  may  be  present.  In  very  acute  cases  the  patient 
becomes  seriously  ill  within  forty-eight  hours,  the  movements  increase  in 
frequency,  the  pain  is  of  great  intensity,  severe  headache  occurs,  and  the 
patient  becomes  dehrious  and  dies  on  the  third  or  fourth  day.  Lobar 
pneumonia,  bronchopneumonia,  acute  bronchitis,  and  fibrinopurulent 
pleurisy  may  complicate. 

In  cases  of  moderate  severity  the  symptoms  abate,  stools  lessen  in 
frequency,  temperature  falls,  and  within  two  or  three  weeks  the  patient 
is  convalescent.  In  the  subacute  cases  the  attack  may  last  many  weeks 
or  even  months,  and  the  patient  have  three  to  five  bloody  mucous  stools 
in  twenty-four  hours,  and  become  very  emaciated.  One  of  Strong's  cases 
died  on  the  sixty-fourth  day.  The  Bacillus  dysenteriae  is  found  in  the 
stools  and  agglutinates  with  blood-serum. 

Other  Clinical  Types. — The  description  just  given  applies  to  the 
types  of  bacillary  dysentery  such  as  seen  in  Japan,  the  Philippines,  and 
the  tropics,  and  the  features  of  that  in  adults  in  temperate  climates  differ 
in  no  essential,  except  in  many  cases  the  symptoms  are  less  severe. 

Duval,  as  noted,  has  found  one  of  the  bacillary  dysentery  strains  in 
sporadic  cases  in  Philadelphia  and  elsewhere,  and  the  probability  is  that 
.  most  cases  of  non-amebic  dysentery  belong  to  this  type. 

The  so-called  acute  catarrhal  dysentery  is  unquestionably  a  sporadic 
form  due  to  the  Bacillus  dysenteriae.  This  is  the  more  probable  when 
we  consider  that  in  ileocolitis  (dysentery)  in  infants  we  find  a  catarrhal 
type.  In  infants  there  are  four  types  of  lesion  found  on  autopsy 
(Holt): 

Follicular  ulceration;  catarrhal  inflammation;  catarrhal  inflammation 
with  superficial  ulceration;  membranous  inflammation. 

This  last  differs  from  the  membranous  type  in  adults,  in  that  there 
is  little  pseudomembrane  and  no  deep  sloughing.  Holt  has  well  described 
these  varieties. 

Methods  of  serum  diagnosis  in  the  bacillary  dysentery  of  infants  are 
described  by  Lucas  and  Fitzgerald^  at  the  laboratories  of  the  Harvard 
Medical  School.  They  advocate  the  conglutination  reaction.  His 
and  Russell  some  years  ago  differentiated  the  Y  bacillus  as  causative  of 
dysentery  in  infants  and  young  children.  Two  epidemics  of  this  type 
occurred  among  children  in  Diisseldorf  and  Berlin  in  the  summer  and 
fall  of  1912. 

Diphtheritic  dysentery  is  a  type  of  the  bacillary  form  with  great 

necrosis  and  infiltration  of  the  mucosa.     It  is  beUeved  that  other  types 

of  bacteria  are  also  often  associated  in  the  process.     The  pure  dysentery 

bacillus,  unlike  the  typhoid  bacillus,  does  not  lead  to  bacillemia  or  bacil- 

^  Jour.  Amer.  Med.  Assoc,  Feb.  s,  1910. 


696  DISEASES   OF   THE    STOMACH    AND    INTESTINES 

luria  (Herter,  Bacterial  Infections  of  the  Digestive  Tract).  In  the 
diphtheritic  type,  a  mixed  infection  in  which  streptococci  undoubtedly 
are  prominent,  the  condition  is  unquestionably,  in  my  opinion,  a  general 
infection,  as  shown  by  the  complications. 

The  secondary  diphtheritic  dysentery  is  a  common  terminal  event 
in  many  acute  and  chronic  diseases.  Vedder  and  Duval  have  demon- 
strated that  the  bacilli  are  present  in  these  cases. 

Peritonitis  is  rare,  either  through  extension  or  by  perforation.  When 
it  occurs  about  the  cecal  region,  perityphlitis  results,  or  when  low  down, 
periproctitis. 

In  108  cases  collected  by  Woodward,  perforation  occurred  in  11. 

Abscess  of  the  liver  is  very  rare.  A  few  cases  occurred  in  the  Civil  or 
South  African  War.  In  the  tropics  malaria  and  dysentery  may  coexist, 
and  typhoid  and  dysentery  coexisted  quite  frequently  in  the  Civil  War. 
In  ordinary  practice  it  is  very  rare. 

Complications. — Acute  bronchitis,  pneumonia,  bronchopneumonia, 
cancrum  oris,  pleurisy,  gangrene  of  the  lung,  albuminuria,  meningitis, 
paralysis,  paraplegia,  in  many  cases  due  to  a  neuritis,  are  not  uncommon; 
thrombosis  of  the  cerebral  sinuses,  embolism  (cerebral),  rheumatic  pains 
and  swollen  joints  (analogous  to  gonorrheal  arthritis),  pericarditis,  endo- 
carditis, periproctitis,  perityphlitis,  and  occasionally  pyemic  manifesta- 
tions, such  as  pylephlebitis  or  abscess  of  the  spleen,  may  occur.  Anemic 
edema  may  be  present  in  protracted  cases.  Chronic  Bright's  disease  is 
an  occasional  sequel  and  intestinal  stricture  is  rare.  Persistent  dyspepsia 
and  irritability  of  the  bowels  may  follow. 

Prognosis. — In  the  very  severe  cases,  the  prognosis  is  bad,  the  patient 
often  dying  within  one  to  two  weeks.  This  is  especially  true  in  epidemics. 
In  milder  cases  convalescence  begins  by  the  end  of  the  second  week. 
Chronic  cases  may  run  weeks  or  even  months,  the  patient  becoming  very 
emaciated.  They  may  die  at  the  end  of  several  months.  Convalescence 
is  slow  in  any  but  the  mild  cases. 

Treatment. — Prophylaxis. — The  same  precautions  should  be  exercised 
as  regards  boiling  drinking-water,  avoiding  green  vegetables,  cleanliness 
of  the  hands,  destruction  of  flies  disinfection  of  stools  and  linen,  as  are 
carried  out  in  amebic  dysentery  and  in  typhoid  fever. 

Medication. — The  bowels  should  be  at  once  thoroughly  cleared  with 
castor  oil,  i  to  2  ounces  (30.0-60.0), or  with  magnesium  sulphate  or  sodium 
sulphate,  i  to  2  drams  (4.0-8.0).  Buchanan  has  had  excellent  results  by 
the  sodium  sulphate  treatment;  he  gives  i  dram  (4.0)  sodium  sulphate 
four  to  even  eight  times  a  day,  for  two  to  three  days  until  blood  and 
mucus  have  disappeared.  He  has  treated  855  cases  with  nine  deaths — an 
excellent  record. 

The  old  ipecac  treatment  is  still  in  considerable  repute  in  tropical 
countries.  No  food  is  taken  for  three  hours,  then  20  drops  of  laudanum 
are  administered  and  one-half  hour  later  20  to  60  grains  (1.3-4.0)  of  pul- 
verized ipecac.  If  this  is  vomited,  the  dose  is  repeated  in  a  few  hours. 
The  salol-coated  ipecac  pill,  as  described  under  Amebic  Dysentery,  may 
be  substituted,  or  emetin  preferably  by  hypodermic.  Rogers  claims 
that  emetin  has  no  effect  on  the  bacillary  type  and  it  may  be  used  as  a 


DYSENTERY  697 

means  of  differential  diagnosis,  i.e.,  favorable  results  show  the  dysentery 
is  amebic. 

In  South  Africa  the  saline  treatment  was  often  given  combined  later 
with  the  ipecac,  and  Washbourne  reported  good  results. 

Ringer  recommends  small  doses  of  bichlorid,  Koo  grain  (0.00065), 
every  two  to  three  hours,  and  large  doses  of  bismuth  subnitrate  have  been 
used  with  success,  at  least  >^  dram  (2.0)  and  sometimes  as  much  as  i  dram 
(4.0)  every  two  hours  daily  for  the  first  few  days.  The  following  I  have 
found  the  most  rational  method  of  internal  medication. 

The  bowels  should  first  be  thoroughly  cleared  by  the  administration 
of  ij^  to  2  ounces  (45.0-60.0)  of  castor  oil  in  the  adult,  or  by  several  doses 
of  I  to  2  drams  (4.0-8.0)  of  magnesia  sulphate  or  sodium  sulphate;  calomel, 
5  grains  (0.3),  may  precede  this.  A  hot  application  should  meanwhile 
be  applied  to  the  abdomen  to  relieve  the  pain,  and  if  the  latter  be  un- 
endurable and  there  is  considerable  collapse,  a  very  small  hypodermic  of 
.  morphin  may  be  given,  sufficient  to  render  it  endurable  and  not  large 
enough  to  interfere  with  peristalsis.  Camphor  gr.  v-x  in  almond  oil  by 
hypo  may  also  be  required.  It  is  preferable  not  to  administer  opiates 
until  thorough  cleansing  of  the  bowels  has  been  accomplished.  In  fact, 
it  is  m,y  belief  that  opium  is  given  too  frequently  and  in  too  large  doses, 
so  that  material  accumulates  in  the  bowel  which  had  better  be  expelled. 

Bismuth  subnitrate,  which  it  is  preferable,  as  a  rule,  not  to  use  in  the 
undermined  ulcers  of  amebic  dysentery,  in  this  type  is  of  great  value. 
The  dose  should  be  large.  After  thorough  clearing  of  the  bowels,  bismuth 
subnitrate  alone,  or  combined  with  equal  parts  of  saccharated  pepsin 
should  be  given. 

At  least  20  to  30  grains  (1.3-2.0)  of  this  mixture  or  even  20  grains 
(2.6)  of  bismuth  subnitrate  every  two  to  three  hours.  Bismuth  subcar- 
bonate,  10  to  15  grains  (0.6-1.0),  can  be  substituted.  Bismuth  subgallate, 
5  to  10  grains  (0.3-1.6)  t.i.d.,  or  bismuth  salicylate,  10  grains  (0.6)  t.i.d., 
can  be  substituted  in  place  of  some  of  the  usual  doses  of  the  other  prepara- 
tions; thus,  for  example,  bismuth  subgallate  and  bismuth  subnitrate 
could  alternate.  Bismuth  subnitrate,  30  grains  (2.0),  mistura  cretae, 
2  drams  (8.0),  is  an  excellent  combination  in  one  dose,  given  every  three 
or  four  hours.  The  tannin  preparations,  such  as  were  suggested  in 
amebic  dysentery,  can  be  given,  three  doses  substituted  for  three  of  the 
bismuth  in  the  course  of  twenty-four  hours.  Thus,  if  seven  doses  of 
bismuth  were  given  in  twenty-four  hours,  give  three  of  tannin  and  four 
of  bismuth.  Tannalbin,  5  to  7H  grains  (0.3-0.5),  or  even  15  to  30  grains 
(1.0-2.0),  can  be  given  four  or  five  times  daily.  It  can  be  administered 
with  grated  chocolate  or  beaten  up  with  an  egg  or  with  a  little  strained 
rice  gruel.  Tablets,  5  grains  (0.3),  can  also  be  secured.  If  the  pain  is 
severe,  small  doses  of  opium  may  have  to  be  given,  with  the  precautions 
noted.  The  opiates  are  described  under  Diarrhea.  Hexamethylen- 
amin  I  believe  is  of  service,  5  to  10  grains  (0.3-0.6),  combined  with  equal 
quantities  of  sodium  benzoate,  given  four  to  six  times  daily.  It  tends  to 
lessen  the  toxemia  and  is  of  service  in  the  cases  of  mixed  infection. 

Tenesmus  should  be  relieved  first  by  thorough  bowel  irrigation,  and 
after  this,  if  it  continue,  by  inflation  with  a  small  amount  of  CO2  (Rose's 


698  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

method),  or  by  a  small  injection  of  starch- water  and  laudanum,  15  minims 
(0.888),  with  tincture  of  belladonna,  10  minims  (0.59).  Opium  should 
never  be  given  first,  thus  tying  up  the  foul  secretions. 

Strychnin,  nitroglycerin,  or  camphorated  oil  by  hypodermic  may  be 
required.  Local  treatment  is  of  paramount  importance.  Zinc,  sulpho- 
carbolate  of  zinc,  and  silver  nitrate  are  preferable  in  the  chronic  cases. 
Hypodermoclysis,  or  even  infusion,  may  be  required  in  shock  or  severe 
sepsis  or  thirst.     Proctoclysis  is  of  use  in  the  latter. 

Further  Treatment  of  Tenesmus. — A  preliminary  suppository  of  bella- 
donna extract,  yi  grain  (0.022),  alone  or,  rarely,  combined  with  J^  grain 
(0.008)  cocain,  or  the  injection  of  %  grain  (0.008)  cocain  in  i  ounce  (30.0) 
water,  may  rarely  be  necessary.  The  best  method  is  to  insert  a  recur- 
rent tube  and  gently  irrigate  with  normal  saline  solution  at  110°  to  ii5°F., 
or  cold  at  40°  to  5o°F.,  and  then,  forcing  the  tube  in  still  further,  con- 
tinue the  antiseptic  irrigation. 

I  have  found  the  recurrent  method  of  irrigation  with  a  double  tube 
(preferably),  or  two  tubes  (soft  catheters)  of  great  value  in  dysentery, 
the  patient's  hips  or  foot  of  the  bed  being  elevated.  The  patient  is 
gradually  accustomed  to  the  fluid,  and  the  quantity  allowed  to  run  in 
before  permitting  return,  can  slowly  be  increased,  and  there  is  not  the 
endeavor  to  expel  the  solution.  A  single  injection  of  any  size  can  often 
not  be  given. 

On  the  other  hand,  i  to  i>^  liters  (quarts)  can  be  injected,  by  the 
method  of  Musgrave  in  amebic  dysentery,  in  some  cases. 

In  the  acute  cases  acetozone,  alphozone,  hydrogen  peroxid,  and  per- 
manganate of  potash  are  of  especial  value,  in  the  same  strength  noted 
below  as  employed  in  amebic  dysentery. 

Delafield  has  secured  excellent  results  by  the  use  of  bichlorid  of  mercury 
(i  :  10,000),  using  2  quarts  (liters),  but  cautiously,  with  my  recurrent 
tube.  I  have  had  good  results  by  this  method,  but  it  should  never  be 
given  by  ordinary  enema. 

Acetozone  (i  :  1000),  hydrogen  peroxid  5ii  to  liter  of  water,  alphozone 
(i  :  1000),  and  permanganate  of  potash  (i  :  1000)  are  excellent. 

Mucol,  I  dram  (4.0)  to  i  quart  (liter)  or  even  stronger,  has  been  em- 
ployed. This  preparation  contains  the  chlorid,  borate,  bicarbonate,  and 
benzoate  of  soda,  with  zinc  sulphocarbolate  and  essential  oils. 

Several  irrigations  or  enemata  may  be  necessary  daily,  depending  on 
the  tenesmus,  or  character  of  the  stool:  one  or  two  antiseptic,  and  the  rest 
of  normal  saline  solution,  or  flaxseed  tea  or  gum-arabic. 

If  mucus  and  blood  increase,  a  cathartic  is  again  indicated,  and  I 
believe  it  should  be  given  every  three  days  in  any  event. 

Carbolic  acid  should  never  be  employed  for  irrigation. 

Chronic  Dysentery. — Bismuth  is  of  value.  Nitrate  of  silver  injections 
are  of  service — 10  to  30  grains  (0.6-2.0)  to  i  pint  (500  c.c.) —  and  inject 
2  to  3  pints  if  possible;  if  there  is  irritation,  follow  it  with  an  injection  of 
normal  saline  solution. 

Protargol  or  argyrol  (i  :  500)  are  useful,  and  often  preferable  to  silver 
nitrate. 

Normal  saline  or  normal  saline  with  oil  of  peppermint,  10  minims 


DYSENTERY  699 

(0.59),  can  be  used  between  the  antiseptic  injections,  or  an  injection  of 
flaxseed  tea  or  gum-arabic  solution.     The  latter  are  soothing. 

Diet. — Acute  Cases. — Fluid  diet,  broths,  gruels,  barley-  and  rice-water, 
beef  juice,  egg-albumen,  and  milk  well  diluted.  Somatose  and  tropon  are 
of  use.     Personally  I  prefer  milk-free  diet. 

In  the  chronic  cases,  fruits  and  green  vegetables  should  be  avoided 
and  constipating  food  given  if  there  is  diarrhea.  The  weight  of  the 
patient  should  be  increased  by  administration  of  fats,  cream,  butter  and 
raw-eggs.  The  general  diet  rules  should  be  similar  to  those  in  amebic 
dysentery. 

Serum  Therapy. — Shiga  immunized  horses  and  produced  a  polyvalent 
serum  from  which  he  claims  to  have  reduced  the  mortality  of  dysentery 
in  Japan  from  35  to  9  per  cent. 

Flexner  has  prepared  a  serum,  but  Holt  states  results  in  children 
have  proved  disappointing. 

Complications  should  receive  appropriate  treatment. 

Treatment  of  Dysentery  Bacilli  Carriers. — Mayer^  states  that  at- 
tempts to  dispossess  these  bacilli  by  internal  medication  have  failed. 
He  advises  isolation  until  the  germs  disappear  from  the  stools.  This 
has  been  found  to  require  from  three  to  seven  months.  The  author  refers 
chiefly  to  cases  in  troops  where  sanitary  measures  are  more  available 
and  where  the  danger  of  lighting  up  new  epidemics  is  more  marked. 
In  addition  to  isolation,  the  stools  require  immediate  disinfection.  It  has 
been  found  that  if  the  period  of  isolation  is  too  short,  bacilli  which  have 
temporarily  disappeared  from  the  stools  may  reappear.  Meanwhile 
treatment  should  be  continued  and  the  effort  made  to  prevent  the  con- 
dition from  becoming  chronic.  Hexamethylenamin  and  sodium  benzoate 
(aa  gr.  x),  four  to  six  times  daily,  and  high  irrigations  with  acetozone 
(i  :  1000)  should  be  continued. 

1  Munch,  medizia.  Wochens.,  Dec.  6,  1910. 


CHAPTER  XXVII 
TYPHOID  FEVER— PARATYPHOID  FEVER— BRILL'S  DISEASE 

A  MERE  outline  of  this  disease  will  be  given  for  the  purpose  of  dif- 
ferential diagnosis.  Typhoid  may  be  defined  as  a  general  infection  caused 
by  the  Bacillus  typhosus,  characterized  anatomically  by  hyperplasia  and 
ulceration  of  the  intestinal  lymph-follicles,  swelling  of  the  mesenteric 
glands  and  spleen,  and  by  parenchymatous  changes  in  the  other  organs, 
such  as  in  the  kidneys,  liver,  etc.  Clinically  the  disease  is  marked  by 
fever,  rose-colored  eruption,  abdominal  tenderness,  tympanites,  diarrhea, 
and  splenic  enlargement,  but  these  symptoms  are  inconstant. 

Histoiy. — Louis,  in  1829,  gave  the  name  to  the  fever.  Gerhard,  in 
1837,  first  clinically  differentiated  between  typhoid  and  typhus. 

Etiology. — General  prevalence.  It  prevails  in  temperate  climates. 
Imperfect  sewage  and  contaminated  water-supply  favor  the  distribution 
of  the  bacilli;  filth,  overcrowding,  and  bad  ventilation  aid  in  lowering 
the  resistance  of  the  individual.  Fingers,  food,  and  flies  spread  the 
disease  from  the  infected  person.  It  is  prevalent  in  England,  Wales, 
India,  parts  of  Germany,  and  in  the  United  States,  where  it  occupies  about 
fourth  place  in  the  mortality  list.  It  has  been  one  of  the  great  scourges 
of  armies,  more  desctructive  than  powder  and  shot.  The  mortality  in 
the  South  African  and  Spanish-American  wars  was  greater  from  typhoid 
than  from  bullet  wounds;  among  the  American  troops,  about  one-fifth 
of  the  soldiers  in  the  national  encampments  had  this  disease.  The 
former  inefficiency  of  our  sanitary  methods  was  a  blot  upon  our  govern- 
ment. In  great  contrast  to  this  were  the  remarkable  results  secured  by 
the  Japanese  in  the  recent  Russo-Japanese  War,  where,  in  comparison 
with  our  own  records,  typhoid  and  dysentery  were  practically  negligible 
factors. 

Season. — The  disease  is  more  prevalent  in  the  autumn,  though  fre- 
quent cases  occur  during  August. 

Sex. — Both  sexes  are  equally  liable,  but  males  are  more  frequently 
admitted  to  the  hospitals. 

Age. — Typhoid  is  a  disease  of  youth  and  early  adult  life,  the  greatest 
susceptibility  being  between  the  ages  of  fifteen  and  thirty.  Cases  are 
rare  over  sixty.  It  is  not  infrequent  in  children.  Infants  are  rarely 
attacked. 

Immunity. — Not  all  exposed  take  the  disease.  One  attack  usually 
protects;  two  attacks  have  been  described,  and  occasionally  three. 

Bacillus  Typhosus. — The  researches  of  Eberth,  Koch,  and  others  have 
shown  that  the  disease  is  due  to  a  special  microorganism.  It  is  a  short, 
thick,  flagellated,  motile  bacillus  with  rounded  ends,  in  one  of  which, 
sometimes  in  both,  there  can  be  seen  a  glistening  round  body,  probably 
an  area  of  degenerate  protoplasm.     It  grows  readily  on  various  nutritive 

700 


TYPHOID   FEVER — PARATYPHOID   FEVER — BRILL 's   DISEASE       7OI 

media  and  must  be  differentiated  from  the  Bacillus  coli.^  The  organism 
fulfils  all  the  requirements  of  Koch's  law.  Cultures  are  killed  in  ten 
minutes  by  a  temperature  of  6o°C.  The  direct  rays  of  the  sun  destroy 
them  in  from  four  to  ten  hours'  exposure.  Bouillon  cultures  are  destroyed 
by  carbolic  acid  (i  :  200)  and  by  bichlorid  (i  :  2500)  solution.  Toxins 
have  been  isolated  from  the  bacilli. 

Distribution  in  the  Body. — The  typhoid  bacilli  may  be  demonstrated 
in  the  circulating  blood,  and  have  been  found  in  the  urine,  stools,  sweat, 
sputum,  and  in  the  rose-spots.  They  occur  in  the  mesenteric  glands, 
spleen,  and  gall-bladder,  and  have  been  found  in  almost  all  the  organs, 
even  in  the  muscles,  uterus,  and  lungs.  Cultures  from  the  intestines 
show  that  few,  and  frequently  none,  can  be  cultivated  from  the  rectum 
up  to  the  cecum.  Above  this  they  are  numerous.  They  have  been  found 
in  the  mucous  membrane  of  the  stomach,  in  the  doudenal  contents,^  also 
in  the  esophagus,  and  on  the  tongue  and  tonsils,  and  have  been  isolated 
from  endocardial  vegetations,  meningeal  and  pleural  exudates,  and  from 
foci  of  suppuration  in  various  parts  of  the  body.  They  may  be  present 
in  the  stools  of  healthy  people  who  have  lived  in  close  association  with 
typhoid  patients. 

Bacilli  Outside  the  Body. — They  retain  their  vitality  for  weeks  in 
water.  This  is  further  demonstrated  from  infection  by  ice,  in  which 
they  exist  for  several  months,  and  live  for  some  days  in  butter  from  in- 
fected cream.  They  may  live  in  the  upper  layers  of  the  soil  for  months; 
in  street  dust  for  a  month  or  more;  on  linen  for  two  months;  and  on  wood 
for  a  month. 

Modes  of  Conveyance. — Aerial  transmission  is  not  probable.  Fingers, 
food,  and  flies  are  the  chief  means.  House  infection  is  difficult  to  avoid 
unless  finger  contamination  is  carefully  eliminated.  Such  epidemics 
have  been  reported  at  the  Johns  Hopkins  Hospital.  Epidemics  have 
occurred  from  infection  of  water,  milk,  and  food,  such  as  celery  and  un- 
cooked vegetables  which  have  grown  in  infected  soil.  Raw  oysters  are 
recorded  as  a  cause  of  epidemics.  Bedbugs  and  fleas  may  be  carriers. 
Water  infection  is  the  most  common  cause.  There  is  some  evidence  that 
the  digestive  tract  is  not  the  only  portal  of  infection  for  typhoid  fever, 
but  that  the  bacilli  may  enter  by  way  of  the  throat,  notably  by  the 
tonsils  (Herter). 

Morbid  Anatomy. — Intestines. — A  catarrhal  condition  exists  throughout 
the  large  and  small  intestine.  Specific  changes  occur  in  the  lymphoid 
elements;  chiefly  in  the  lower  end  of  the  ileum.     Four  stages  are  described: 

I.  Hyperplasia,  involving  Peyer's  patches  in  the  jejunum  and  ileum 
and,  to  a  variable  extent,  those  in  the  large  intestine.  They  are  swollen, 
grayish-white  in  color,  and  may  project  from  3  to  5  mm.  The  solitary 
glands  may  project  to  a  variable  extent. 

There  is  hyperemia  of  the  follicles;  later  an  increase  and  accumulation 
of  the  cells  of  the  lymph-tissue,  which  may  infiltrate  the  adjacent  mucosa 
and  muscularis;  the  blood-vessels  are  compressed,  which  give  a  white 
anemic  appearance  to  the  follicles. 

1  Paratyphoid  infection  is  referred  to  under  Diagnosis. 
*  Purjesz,  Wiener  Klinische  Wocbens.,  Jan.  i,  1914. 


702  DISEASES   OF    THE    STOMACH    AND   INTESTINES 

This  process  reaches  its  height  from  the  eighth  to  the  tenth  day,  and 
then  undergoes  either  resolution  or  necrosis. 

2.  Necrosis.  When  the  hyperplasia  is  marked,  resolution  is  no  longer 
possible.  The  blood-vessels  become  choked;  there  is  a  condition  of 
anemia;  then  necrosis  occurs  and  sloughs  form,  which  must  be  separated 
and  thrown  off.  This  process  is  always  more  intense  toward  the  ileocecal 
valve.  The  necrosis  is  variable,  it  may  pass  deep  into  the  muscular  coat, 
and  even  perforate  the  peritoneum. 

3.  Ulceration.  Sloughing  is  effected  from  the  edges  inward,  and 
results  in  the  formation  of  an  ulcer,  the  extent  of  which  is  directly  propor- 
tionate to  the  amount  of  necrosis.  The  muscularis  usually  forms  the 
floor  of  the  ulcer. 

4.  Healing.  The  mucosa  extends  from  the  edge  and  a  new  growth  of 
epitheUum  is  formed,  as  are  the  glandular  elements.  The  healed  ulcer 
is  depressed.     Healing  is  never  associated  with  stricture. 

Large  Intestine. — The  cecum  and  colon  are  affected  in  about  one-third 
of  the  cases,  and  the  solitary  glands  are  sometimes  enlarged. 

Perforation. — About  one-third  of  the  deaths,  Scott's  statistics  state, 
are  due  to  perforation.     It  occurred  in  3.6  per  cent,  of  all  cases. 

The  German  statistics  are  much  lower;  in  Munich  only  5.7  per  cent, 
of  deaths  are  due  to  perforation.  Among  1500  cases  at  the  Johns  Hopkins 
Hospital  there  were  43  of  perforation;  20  were  operated  on,  and  7  of  these 
recovered.  The  site  of  the  perforation  is  usually  in  the  ileum,  within  12 
inches  of  the  ileocecal  valve.     It  may  be  from  a  pin-point  to  large  size. 

Death  from  Hemorrhage. — This  occurred  in  12  of  137  deaths  in  Osier's 
1500  cases.     He  could  not  find  the  bleeding  vessels. 

Mesenteric  glands  are  h5^eremic  and  swollen.  Necrosis  is  common; 
abscesses  may  occur,  causing  peritonitis  or  hemorrhages. 

Spleen  is  enlarged,  infarction  is  not  infrequent.     Rupture  may  occur. 

Bone-marrow. — Some  changes  occur  as  in  lymphoid  tissue,  and  there 
may  be  foci  of  necrosis. 

Liver. — Parenchymatous  degeneration  present.  Liver  abscess  has 
been  found,  also  acute  yellow  atrophy.     Pylephlebitis  may  occur. 

Gall-bladder. — Acute  cholecystitis  may  be  present. 

Kidneys. — Cloudy  swelling  with  granular  degeneration  is  frequent; 
less  commonly  an  acute  nephritis;  miliary  abscesses  or  diphtheritic  in- 
flammation of  the  pelvis  may  occur;  also  infection  by  colon  bacilli.  With 
colon  bacilli  infection,  chills,  rise  of  temperature,  and  acute  renal  symptoms 
occur. 

Bladder. — Cystitis  or  diphtheritic  inflammation  may  complicate. 
Orchitis,  acute  mastitis,  and  parotiditis  are  occasionally  met  with. 

Respiratory  Organs. — Ulcer  of  the  larynx;  edema  of  the  glottis;  diph- 
theritic inflammation;  bronchitis;  pneumonia;  hypostasis,  pleurisy; 
gangrene;  abscess  of  the  lung;  hemorrhagic  infarction  and  empyema  may 
complicate. 

Osseous  System. — Periostitis,  osteitis,  etc.,  are  referred  to  later. 

Circulatory  Changes. — Endocarditis,  pericarditis,  and  myocarditis, 
endarteritis,  arthritis  of  a  peripheral  vessel  with  thrombus  formation  may 
occur.     Venous  thrombosis  is  more  frequent,  especially  of  the  left  femoral. 


TYPHOID    FEVER PARATYPHOID   FEVER — ^BRILL'S    DISEASE       703 

Nervous  Symptoms. — Meningitis  is  rare;  optic  neuritis  may  occur; 
the  cause  of  aphasia  seen  in  children  is  not  positively  known.  Paren- 
chymatous changes  may  occur  in  the  peripheral  nerves. 

Voluntary  Muscles. — The  muscular  substance,  especially  of  the  recti, 
pectorals,  and  adductors  of  the  thigh,  may  undergo  granular  degenera- 
tion or  hyaline  transformation.  Rupture,  hemorrhage,  or  abscess  have 
been  found. 

Reflexes. — The  superficial  skin  reflexes  of  the  abdominal  walls  are  fre- 
quently absent  or  markedly  diminished  in  typhoid  fever.  The  return 
of  these  lost  reflexes  is  usually  synchronous  with  other  evidences  of 
recovery. 

Symptoms. — Incubation,  eight  to  fourteen  days,  occasionally  to 
twenty-three  days,  during  which  period  there  are  lassitude  and  inapti- 
tude for  work.     Onset  is  rarely  abrupt,  with  occasional  chills.     There 


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may  be  cough  (bronchitis),  epistaxis,  headache,  anorexia,,  diarrhea  in 
many  cases,  but  frequently  early  constipation,  abdominal  pain,  and  dis- 
tention; and  in  some  cases  there  is  pain  in  the  right  iliac  fossa.  At  the 
onset  the  patient  usually  takes  to  his  bed. 

During  the  first  week  there  is  in  many  cases  a  steady  rise  of  tem- 
perature, the  evening  record  rising  a  degree  or  more  each  day,  and  reach- 
ing 103°  to  io4°F.  (Fig.  294).  Variations  of  temperature  are  common. 
It  may  rise  suddenly  to  io4°F.  or  may  fall  suddenly.  It  may  be  high 
A.  M.  and  lower  p.  m. 

The  pulse  is  rapid,  100  to  no,  full,  but  of  low  tension,  and  often 
dicrotic.  The  tongue  is  coated  and  white,  the  abdomen  slightly  dis- 
tended and  tender.  Unless  there  is  high  temperature,  there  is  no  delirivmi. 
The  patient  complains  of  headache  and  there  may  be  mental  confusion 
at  night.    The  bowels  are  loose,  or  may  be  constipated.     At  the  end  of 


704  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

the  week  the  spleen  becomes  enlarged  and  the  eruption  appears  in  the 
form  of  rose-colored  spots,  seen  first  on  the  abdomen.  They  are  raised, 
flattened  papules,  can  be  felt  by  the  finger,  and  disappear  on  pressure. 
They  come  out  in  crops  and  may  appear  on  the  trunk  or  extremities. 
Desquamation  may  occur. 

In  the  second  week  the  symptoms  become  aggravated;  the  fever  re- 
mains high  and  the  morning  remissions  are  slight,  the  pulse  is  rapid  and 
loses  its  dicrotism.  There  are  mental  torpor  and  dulness;  the  lips  are 
dry  and  the  tongue  may  become  dry.  Tympanites,  tenderness,  and 
diarrhea,  if  present,  become  aggravated.  The  stools  are  described  as 
"pea-soup."  Death  may  occur  at  the  end  of  this  week  from  hemorrhage 
or  perforation,  but  generally  later.  In  the  third  week  the  pulse  ranges 
f]?om  no  to  130.  The  temperature  shows  marked  morning  remissions 
and  there  is  a  gradual  decline  in  the  fever.  Loss  of  flesh  is  more  marked 
and  weakness  is  pronounced. 

Diarrhea  and  meteorism  may  in  some  cases  occur  for  the  first  time. 
Unfavorable  symptoms  are  pulmonary  complications,  feebleness  of  the 
heart,  delirium  with  muscular  tremor,  and  acute  tympanites.  The  tongue 
may  become  brown  or  brownish  black  and  the  lips  and  teeth  be  covered 
with  sordes. 

Special  dangers  are  perforation  and  hemorrhage. 

The  fourth  week  convalescence  begins.  Temperature  gradually  be- 
comes normal;  diarrhea  stops;  tongue  cleans;  the  desire  for  food  returns. 
In  severe  cases  the  fourth  and  fifth  weeks  present  an  aggravated  picture  of 
the  third,  the  patient  grows  weaker,  pulse  more  rapid  and  feeble,  tongue  dry, 
and  abdomen  distended.  He  lies  in  profound  stupor  with  low  muttering 
delirium  and  subsultus  tendinum,  and  passes  the  feces  and  urine  invol- 
imtarily.    Heart-failure  and  secondary  complications  are  the  chief  dangers. 

In  the  fifth  and  sixth  weeks,  protracted  cases  show  irregular  fever, 
and  convalescence  may  not  set  in  until  the  fortieth  day  or  longer.  Dur- 
ing this  period,  recrudescence  of  temperature  may  occur  from  errors  in 
diet,  constipation,  or  excitement;  or  a  relapse  (re-infection)  may  take  place. 
With  relapse,  there  is  a  repetition  of  the  ascent  of  the  original  fever.  A 
rise  in  temperature  from  inflammatory  complications  usually  has  leuko- 
cytosis associated  with  it. 

Modes  of  Onset. — As  a  rule,  the  onset  is  insidious.  The  following 
deviations  may  occur:  Marked  nervous  symptoms,  such  as  headache 
or  cerebrospinal  symptoms,  with  retraction  of  the  head  and  convulsions; 
or  mania;  or  stupor.  Pulmonary  symptoms,  such  as  bronchitis,  pneu- 
monia, or  pleurisy.  Intense  gastro-intestinal  symptoms,  with  pain  and 
vomiting,  suggestive  of  poisoning,  or  in  some  cases  simulating  appendicitis. 
Acute  nephritis  may  be  the  first  symptom.  Ambulatory  form,  in  which 
the  patient  keeps  about  and  attempts  to  work.  This  runs  a  severe  course 
and  often  a  fatal  issue  results.  Chills  may  occur  at  the  onset  and  may 
be  followed  by  sweats,  and  they  are  present  with  complications.  Varia- 
tions from  the  typic  temperature  are  common,  the  step-like  ascent  does 
not  always  occur,  but  the  fever  may  rise  suddenly.  A  sudden  fall  of 
temperature  is  suggestive  of  hemorrhage,  before  blood  appears  in  the  stools. 
Peliomata,  maculae — pale-blue  or  steel-gray  spots — are  sometimes  present, 


TYPHOID   FEVER — PARATYPHOID   FEVER — ^BRILL's   DISEASE       7051 

due  to  lice.  Erythema  may  occur.  Bed-sores  are  not  uncommon  and 
boils  are  a  troublesome  sequel. 

Blood. — Leukopenia  (hypoleukocytosis)  is  present;  lymphocytes  are 
relatively  increased.  Eositwphiles  disappear  or  are  markedly  diminished. 
The  reappearance  or  increase  of  eosinophilia  is  a  good  prognostic  sign. 
leukopenia  and  absence  of  eosinophiles  aid  diagnosis.  Hemoglobin  and 
red  corpuscles  are  reduced. 

Severe  meteorism  is  a  danger-signal  and  predisposes  to  hemorrhage  or 
perforation.  Acute  gastro-intestinal  dilatation,  or  acute  ectasia  alone 
may  occur.  Acute  distention  may  even  simulate  perforation;  and  it  is 
only  possible  to  differentiate,  by  relieving  the  distention  by  enteroclysis 
and  lavage. 

Symptoms  of  Perforation. — Sudden  sharp  pain,  at  times  paroxysmal, 
often  in  the  hypogastric  region  to  the  right  of  the  median  line  sometimes 
lower  down;  tenderness,  sudden  distention,  and  muscular  rigidity.  This 
last  is  an  important  symptom.  There  are  shock,  fall  of  temperature,  pallor, 
sweating,  and  the  Hippocratic  facies.  The  temperature  then  rises,  pulse 
rapid  and  feeble,  respiration  increases.  Vomiting  is  often  present. 
Leukocytosis  and  especially  increase  in  the  polynuclears  occur.  Percus- 
sion may  show  a  flat  note  in  the  flank,  due  to  exudate.  Obliteration  of 
liver  flatness  may  be  caused  by  tympany. 

Abscess  of  the  liver  and  cholecystitis  may  complicate.  Gall-stones 
in  many  cases  are  probably  associated  with  the  presence  of  typhoid  bacilli 
in  the  gall-bladder.  Under  Lesions,  most  of  the  complications  are  referred 
to.    Loss  of  hair  may  take  place. 

Local  neuritis,  as  in  the  arms,  legs,  or  toes  (tender  toes),  may  occur. 
Multiple  neuritis  is  a  complication  of  convalescence.  PoliomyelitiSf 
tetany,  and  hemiplegia  have  been  reported.  Typhoid  psychoses  may 
occur,  also  eye  and  ear  complications,  and  retention  of  urine.  Post- 
typhoid anemia  may  be  severe. 

Ehrlich's  Diazo-reaction. — This  test  is  not  absolutely  diagnostic,  as 
it  occurs  in  miliary  tuberculosis,  in  malaria,  and  occasionally  in  other  acute 
disease,  associated  with  high  fever.  It  is  of  accessory  value  taken  with 
other  data.  Bacilluria  occurs  in  about  one-third  of  the  cases.  Acute 
appendicitis  may  complicate. 

Osseous  System. — Periostitis,*  osteitis,  caries,  and  necrosis  are  trouble- 
some sequelae  of  typhoid,  as  are  arthritis  and  typhoid  spine.  Colitis, 
simple  catarrhal  or  of  a  septic  (diphtheritic)  type,  may  complicate. 

Thrombosis  of  the  Veins. — The  writer  has  recently  seen  a  case  of 
thrombosis  of  the  left  femoral  vein  which  resulted  in  the  ultimate  necessity 
of  amputation  of  the  thigh. 

Post-typhoid  septicemia  and  pyemia  are  not  uncommon.  Furuncles, 
abscesses,  and  infarcts  in  various  regions  may  occur.  With  children, 
t)^hoid  fever  often  runs  a  mild  and  irregular  course. 

Diagnosis. — The  type  of  temperature,  splenic  enlargement,  eruption, 

absence  of  leukocytosis  (leukopenia),  disappearance  of  the  eosinophiles, 

together  with  Ehrlich's  reaction,  are  the  chief  signs.     Isolation  of  the 

typhoid  bacilli  from  the  blood,  stools,  and  urine  is  diagnostic. 

^  The  writer  has  seen  several  cases  of  periostitis  involving  the  ribs  and  femur, 
within  a  few  years. 

45 


7o6  DI^ASES    OF   THE    STOMACH    AND   INTESTINES 

Widal's  reaction  is  of  positive  value  when  found.  It  is  generally  not 
in  evidence  until  the  seventh  to  tenth  day,  sometimes  not  until  con- 
valescence, and  occasionally  not  at  all.  Cabot  claims  over  90  per  cent, 
reactions  before  the  eighth  day.  Fortunately,  it  is  present  in  about  go 
per.cent.  of  cases.  Blood  examination  will  differentiate  between  typhoid 
and  malaria.  Sasky^  concludes  that  bacteremia  is  an  almost  constant 
occurrence  in  the  first  week  of  the  disease  and  tends  to  disappear  in  the 
course  of  the  following  weeks.  In  the  severe  and  moderately  severe 
cases  the  typhoid  bacilli  may  be  isolated  from  the  blood  in  the  second, 
and  even  in  the  third  weeks  of  the  disease,  while  in  the  mild  cases  they 
are  no  longer  to  be  found  in  the  second  week.  Ulcerative  endocarditis 
has  been  mistaken  for  typhoid,  but  the  presence  of  the  heart  lesion  and 
the  streptococci  in  the  blood  are  diagnostic.  With  acute  miliary  tuber- 
culosis the  temperature  is  irregular  or  intermittent.  Tubercle  bacilli 
may  be  found  in  the  fluid  by  lumbar  puncture,  and  there  is  an  absence  of 
t3^hoid  bacilli  in  the  blood-culture.  The  tuberculin  test  (ocular)  or 
by  injection  is  of  value.  Respiration  is  more  rapid  and  there  is  more 
cyanosis.  Widal  is  negative,  but  leukocytosis  is  common.  With  typhoid 
we  have  the  Widal  reaction;  there  is  leukopenia,  splenic  enlargement  is 
present,  and  the  typic  eruption.  Intestinal  grip  may  for  a  few  days 
simulate  typhoid,  as  may  intestinal  toxemia.  The  subsequent  course, 
absence  of  Widal  reaction,  etc.,  clear  the  diagnosis. 

The  paratyphoid^  bacilli  A  and  B  may  produce  symptoms  like  a  mild 
typhoid  fever,  and  paratyphoid  B  may  be  found  in  meat-poisoning,  and 
have  a  causal  relation  to  the  typhoidal  symptoms.  The  Bacillus  enteri- 
tis (Gartner)  may  be  found  in  meat-poisoning,  and  this  bacillus,  and 
also  the  Bacillus  faecalis  alcaligenes,  Herter  shows,  may  incite  symptoms 
simulating  mild  typhoid  fever.  Recent  studies,  however,  have  shown 
that  these  bacilli  differ  from  typhoid  bacilli  in  their  agglutination  reactions. 
Hemorrhage  is  rare  and  never  alarming.  Widal  is  negative.  Moreover, 
the  serums  of  patients  ill  with  meat-poisoning,  regularly  agglutinate  known 
cultures  of  the  causative  organism,  as  does  that  of  paratyphoid  A.  With 
Brill's  disease,  cultures  from  the  blood,  urine,  and  feces  are  negative  as 
to  typhoid  bacillus,  and  Plotz  organism  is  found  with  blood.  Widal  is 
negative.     There  is  na  intestinal  hemorrhage.    Leukopenia  is  absent. 

Prognosis. — Mortality.  Death-rate  is  variable,  depending  on  the  sever- 
ity of  the  epidemic  and  when  treatment  has  begun.  Of  recent  years  it  has 
been  from  5  to  20  per  cent.  Fat  people  stand  typhoid  badly.  Meteorism, 
hemorrhage,  high  fever,  and  nervous  symptoms  give  a  bad  prognosis. 

Prophylaxis. — Care  in  drainage  and  water-supply  are  most  important. 
These  are  the  chief  precautions  to  be  taken  in  army  camps.  Vaccine 
therapy  as  a  means  of  prophylaxis  the  writer  also  believes  of  great  value. 
Undoubtedly  this  proved  efl&cacious  during  the  Boer  War  in  the  English 
army,  being  introduced  by  Wright.  RusselP  reports  favorably  on  this 
method  as  a  prophylactic  in  the  U.  S.  Army,  and  refers  to  the  work  of 
Leischmann  in  the  English  army,  and  to  the  results  secured  in  the  German- 

^  Zeitschrift  fiir  Klinische  Medizin.,  vol.  Ixxx,  Nos.  i  and  2,  1914. 

*  Colon  bacilli  infection  may  simulate  typhoid,  but  the  colon  b,  are  found  in  the 
urine  and  respond  to  the  appropriate  fermentation  tests. 

•  N.  Y.  State  Jour,  of  Med.,  Dec.,  1910. 


TYPHOID   FEVER — PARATYPHOID   FEVER — BRILL  S   DISEASE       707 

African  campaign.  Russell  advocates  three  preventive  injections  at 
ten-day  intervals — the  first  injection  of  500,000,000  dead  bacteria,  and 
the  subsequent  doses  of  1,000,000,000  each. 

Antityphoid  Vaccination. — The  results  of  antityphoid  vaccination  in 
the  U.  S.  Army  can  be  characterized  only  as  marvellous.  Russell  reports 
in  an  army  of  90,000  men  in  the  year  1913^  only  three  cases  of  typhoid 
with  no  fatalities. 

It  should  be  obhgatory  in  the  militia,  and  among  hospital  nurses  and 
internes  who  are  exposed  to  typhoid  in  all  public  institutions  and  asylums 
at  the  first  appearance  of  a  typhoid  case  and  it  should  be  administered 
to  one's  patients  as  a  prophylactic  before  summer  vacation,  or  travelling, 
or  when  there  is  an  epidemic  of  typhoid.  In  those  weakened  by  disease 
it  might  do  harm,  and  the  writer  believes  it  might  activate  an  existing 
tubercular  process.  Alcohol  should  be  avoided  as  should  severe  exercise 
during  the  periods  of  vaccination.  Occasionally  a  more  severe  reaction 
occurs  with  headache,  malaise,  chills,  fever,  nausea,  vomiting  and  diarrhea. 
In  view  of  the  difficulty  of  enforcing  proper  sanitary  regulations  in  an 
ignorant  community,  the  writer  believes  that  antityphoid  vaccination  is 
as  necessary  as  vaccination  against  smallpox.  The  Widal  reaction  should 
be  tested  for  when  possible  4  to  6  weeks  later.  Its  appearance  shows  a 
successful  vaccination.  N.  Y.  Board  of  Health  antityphoid  vaccine,  and 
U.  S.  Army  vaccine  are  excellent.  /  advise  all  my  patients  to  be  immun- 
ized against  typhoid. 

Immunity  following  antityphoid  vaccination,  it  has  been  believed  results 
for  about  two  years;  though  more  recently  Gaither^  reports  the  occurrence 
of  five  cases  of  typhoid  from  nine  to  twenty-one  months  subsequent  to 
vaccination  against  the  disease. 

Gay^  has  recently  announced  a  new  antityphoid  vaccine  from  which 
he  claims  practically  no  reaction  results  and  that  it  is  more  certain  and 
confers  a  longer  immunity. 

Antityphoid  Vaccination  in  Childhood. — Russell '  reports  antityphoid 
vaccination  in  cases  of  children.  No  case  of  typhoid  occurred  in  those 
vaccinated.  Revaccination  should  be  performed  more  frequently  in 
children.  The  dose  is  regulated  according  to  the  weight  of  the  child; 
if  one-third  weight  of  adult — then  a  one-third  dose  should  be  given,  but 
it  is  preferable  to  give  a  little  more  vaccine  in  proportion,  and  if  the  child 
increases  rapidly  in  weight  it  should  be  revaccinated.  He  believes  the 
duration  of  immunity  is  about  three  years  but  two  years  as  a  safer  esti- 
mate. Russell  advocates  antityphoid  vaccination  at  least  once  in  in- 
fancy, once  in  childhood,  once  in  youth  and  once  in  adult  life.  I  believe 
in  it  more  frequently. 

Raw  milk,  raw  oysters,  and  uncooked  fruit  and  vegetables  should  be 
avoided  during  an  epidemic.  Raw  oysters  in  New  York  should  generally 
be  avoided,  unless  the  source  of  the  supply  is  known.  A  number  of 
epidemics  have  been  traced  to  infected  oysters  and  a  recent  epidemic  has 
been  attributed  to  this  source  (Brooks)."*    The  urine,  stools,  and  sputum 

1  Jour.  Amer.  Med.  Assoc,  May  2,  1914. 

2  Jour.  Amer.  Med.  Assoc,  Oct.,  10,  1914. 
*N.  Y.  Jour,  of  Med.,  July,  1914. 
*Jour.  Amer.  Med.  Assoc,  May  6,  1916. 


708  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

should  be  disinfected.  The  sputum  can  be  collected  in  cloths  and  burned 
and  bichlorid  (i  :  1000)  or  carbolic  (i  :  20)  used  to  disinfect  the  other  dis- 
charges. About  twice  the  volume  of  the  disinfectant  should  be  mixed  with 
the  stools,  and  it  should  be  left  to  stand  for  two  hours  before  emptying.  For 
disinfection  of  the  bath-water,  H  pound  of  chlorid  of  lime  will  render 
an  ordinary  bath  of  200  liters  sterile  in  one- half  hour  (Babucke).  The 
nurse  should  wear  a  rubber  apron  and  should  wash  it  frequently  with 
carbolic  or  bichlorid.  When  giving  baths,  rubber  gloves,  or  especially 
rubber  finger-tips,  should  be  worn,  and  the  hands  thoroughly  disinfected 
later.  The  hands  have  been  found  to  be  the  source  of  transfer  of  the 
disease  in  about  90  per  cent,  of  the  cases,  ^  which  proves  the  necessity 
of  isolating  these  patients.  All  bedding  and  the  patient's  night-dress 
should  be  soaked  two  hours  in  i  :  20  carbolic  and  then  boiled.  A  special 
cup,  dish,  spoon,  etc.,  should  be  used  for  the  patient,  and  disinfected  on 
each  occasion  after  using.  It  is  best  to  keep  them  in  the  room  and  transfer 
the  food  from  another  vessel  to  the  special  cup  or  dish;  if  in  a  ward,  after 
each  feeding,  they  should  be  placed  in  carbolic  (i  :  20). 

After  recovery,  the  room  should  be  disinfected.  Osier  shows  that 
1. 81  per  cent,  of  cases  of  typhoid  at  the  Johns  Hopkins  have  been  of 
hospital  origin.  I  have  noted  great  carelessness  in  our  hospitals  as  re- 
gards fly  protection,  seldom  observing  screening  of  the  patient  during  the 
fly  season.  Typhoid  cases  should  preferably  be  kept  in  a  special  ward 
to  avoid  the  danger  of  infection  of  otlier  patients  through  carelessness.  Mabon 
demonstrated  this  some  years  ago  at  the  Manhattan  State  Hospital. 

The  method  so  often  followed  in  some  of  our  hospitals  of  treating 
typhoid  in  the  general  medical  ward  the  writer  believes  most  pernicious. 

Chronic  Typhoid  Distributioii. — Many  cases  are  discharged  from  the 
hospitals  while  there  are  still  typhoid  bacilli  in  the  urine  and  stools. 
Examinations  of  these  discharges  should  be  made. 

Hexamethylenamin  5  to  10  grains  (0.3-0.6),  with  an  equal  amount  of 
sodium  benzoate  t.i.d.,  is  excellent  to  disinfect  the  urine.  It  is  generally 
necessary  to  increase  it  to  four  or  five  doses  daily. 

An  interesting  case  of  typhoid  carrier  of  nearly  seven  years'  duration, 
"Typhoid  Mary,"  with  five  small  epidemics  to  her  credit,  is  reported  by 
George  A.  Soper.^  Rosenberger^  gives  a  report  on  the  literature  of 
typhoid  carriers. 

Treatment. — General  Management. — The  patient  should  be  in  a  light, 
well- ventilated  room,  confined  to  bed.  This  should  preferably  be 
single,  with  a  comfortable  mattress,  covered  with  a  blanket,  and  a  rubber 
cloth  placed  under  the  sheet.     Nursing  and  diet  are  the  essentials. 

Diet. — There  is  a  tendency  among  many  practitioners  to  endeavor 
to  increase  the  resisting  power  to  typhoid  by  increased  feeding,  and  who 
hold  that  for  this  purpose  the  patient  should  lose  as  little  weight  as  possible. 
In  some  cases  solid  food  has  been  administered;  in  others  liquids  with 
considerable  dextrose  and  cream. 

W.  Coleman^  advocates  milk,  cream  to  a  pint  daily,  bread  and  butter, 

^  Jour.  Royal  Army  Med.  Corps,  Jan.,  1907. 

*  Jour.  Amer.  Med.  Assoc,  June  15,  1907. 
'N.  Y.  Med.  Jour.,  March  26,  1910. 

*  Jour.  Amer.  Med.  .\ssoc.,  Oct.  9,  1909. 


TYPHOID   FEVER — PARATYPHOID   FEVER — BRILL's   DISEASE       709 

milk-sugar,  and  eggs,  giving  from  4000  to  5500  calories  per  day,  and  re- 
ports good  results.  The  author  disagrees  with  a  method  which  places 
upon  diseased  organs  twice  the  labor  which  they  perform  in  health,  with 
the  dangers  incident  to  excessive  feeding. 

F.  Meara^  employs  milk,  cream,  etc.,  in  his  diet,  toasted  bread,  gruels, 
ice-cream,  etc.  He  is  more  conservative  as  to  forcing  the  quantities,  but 
gives  as  much  as  the  patient  takes  well,  and  diminishes  the  quantity  if 
gastro-intestinal  disturbances  appear. 

C.  W.  Strong^  gives  a  milk-free  diet,  boiled  rice,  6  to  7  ounces  at  a  time, 
being  the  basis  of  his  feeding,  together  with  eggs,  gelatin,  bread,  butter, 
broths,  with  milk-sugar  and  a  little  cane-sugar,  up  to  3500  calories  a  day. 
He  secures  best  results  by  omitting  milk. 

//  has  been  thoroughly  demonstrated  that  no  matter  what  the  intake, 
the  nitrogenous  output  in  this  disease  is  always  markedly  in  excess.^ 

Kocher  has  demonstrated  that  in  fever  there  is  an  actual  destruction 
of  protein  and  that  it  is  difficult  or  impossible  to  maintain  protein  equi- 
librium at  certain  periods  of  febrile  disease  even  with  a  high  calorie 
diet. 

Typhoid  is  an  acute  general  infection,  and  in  such  conditions  all  the 
digestive  functions  are  abnormal.  The  appearance  of  the  tongue,  the  mouth 
and  lips  of  a  typhoid  patient  are  certainly  significant  of  disturbance  of  the 
salivary  glands.  There  is  change  in  the  character  of  the  bile.  Stolmkow"* 
noted  disturbances  in  the  pancreatic  juice;  and  I  recently  referred  to  the 
diminution^  of  motor  power  and  the  lessening,  or  absence  of  hydrochloric 
acid  during  the  high  temperature  of  typhoid  fever.  The  parenchymatous 
changes  in  the  liver  and  kidneys  interfere  with  elimination  by  these 
organs,  and  the  associated  intestinal  catarrh  causes  further  interference 
with  the  digestive  functions.  Du  Bois^  during  his  calorimetric  observations 
in  disease  made  the  following  interesting  statement.  "In  disease  on 
the  other  hand,  the  appetite  is  no  index  of  the  requirement,  and  the  nutri- 
tion of  the  cells  is  at  the  mercy  of  the  physician.  Likewise  the  stomach 
and  kidneys  are  at  his  mercy  and  he  must  regulate  the  diet  so  that  it  will 
nourish  the  cells  without  throwing  too  much  work  on  damaged  organs,  or 
oxidative  functions  of  the  body.''  Hemorrhages,  tympanites  and  relapses 
are  the  writer's  experience  with  excessively  high  calorific  feeding.  Ex- 
cessive feeding,  as  now  advocated  by  some — 3500  to  5500  calories — the 
writer  holds  prolongs  the  temperature,  as  much  detritus  will  be  found  in 
the  bowels,  and  after  the  emptying  of  the  same,  followed  by  proper  milk- 
free  diet,  the  temperature  runs  a  lower  course.  Stuffing  the  patient  is 
done  at  the  expense  of  diminishing  water,  which  the  writer  advocates  in 
large  amounts  to  eliminate  the  toxins.  In  spite  of  the  disturbance  of 
digestive  secretions  many  patients  can  apparently  assimulate  2000  to 
2500  calories  daily  without  distention  and  with  apparent  benefit.  One 
must  individualize,  however,  in  every  case.     Fat  does  not  constitute  resistance 

1  Amar.  Jour.  Med.  ScL,  Jan.,  191 1. 

*  Amer.  Med.,  Oct.,  1910. 

'  Finkler  and  Lichtenfeld,  Central.  fUr  die  Allgemeine  Gesundheitspflege*  1902. 

*  Pfluger,  Archiv  Physiologie. 

'  Med.  Rec,  June  20,  1908,  and  Amer.  Med.,  May,  1909. 

*  Jour.  Amer.  Med.  Assoc,  Sept.  6,  1914. 


7IO  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

and  Jat  people  generally  do  badly  when  infected  with  t)^hoid,  yet  it  seems 
to  be  the  tendency  not  simply  to  diminish  loss  of  weight  as  much  as  possi- 
ble, but  to  increase  the  weight.  The  writer  notes  that  in  quite  a  number 
of  cases  of  high  caloric  feeding,  tissue  loss  occurred  and  the  nitrogen  out- 
put was  in  excess.  Most  of  these  observers  seem  to  have  entirely  over- 
looked the  value  of  gelatin  in  lessening  nirogen  excretion.  Seibert,  in 
1889,  noted  that  the  temperature  and  tympanites  were  lessened  when 
milk  was  withheld,  the  fever  falling  to  99°  or  ioo°F.  on  the  ninth  to  twelfth 
days.  Rectal  irrigations  he  found  of  great  value.  He^  gives  rectal  in- 
jections with  3  pints  of  warm  normal  saline  solution,  preferably  several 
times  a  day  (depending  on  the  case),  thus  irrigating  the  bowel.  During 
the  first  day  of  treatment,  cold  water  only  is  given  as  food.  From  the 
second  day  on,  >^  pint  of  strained  rice,  oatmeal  or  barley  soup,  containing 
the  extract  of  >^  pound  of  meat  and  the  yolk  of  a  fresh  egg,  well  spiced, 
are  given  every  three  hours,  five  times  daily.  From  the  fourth  day  on, 
strained  pea,  lentil,  potato,  and  tomato  soup  with  rice,  were  added  to  the 
menu.  Two  or  three  zwiebacks  were  given  with  the  soup  at  the  end  of  the 
first  week.  Orange-juice  was  given  in  water  three  times  daily.  Egg 
albumen  was  not  given  on  account  of  the  probability  of  forming  toxins. 
Before  each  meal  15  to  25  drops  of  hydrochloric  acid  were  administered  in 
^  ounce  of  water.  No  alcohol  was  given  except  to  topers,  and  cam- 
phorated oil  was  employed  by  hypodermic,  if  stimulation  was  required. 
Cold  baths  were  never  employed,  even  in  hyperpyrexia.  Sponging  was 
added  if  necessary.     Opium  was  only  used  in  bowel  hemorrhage. 

Wm.  N.  Johnson^  has  secured  excellent  results  in  65  cases  of  typhoid 
treated  by  the  milk-free  diet  at  the  Germantown  Hospital.  There  were 
an  extremely  low  percentage  of  distention  and  hemorrhage  and  no  perfora- 
tion. Of  hemorrhage,  6  per  cent.,  ascompared  with  Coleman's  11  per  cent, 
of  hemorrhage  in  one  series  reported.  With  the  excessively  high  calorie 
feeding,  3500  to  5500  calories,  the  writer  has  found  more  tympanites  and 
a  larger  number  of  hemorrhages. 

Lesser^  has  treated  all  fevers  above  102. 5°F.  with  water  alone,  and 
below  this  point  with  broths,  rice-,  and  barley-water,  also  employing 
enteroclysis.  Good  results  were  secured  by  these  methods  in  typhoid 
fever  during  the  Spanish-American  War, 

The  author's  method  is  as  follows:  As  gelatin  lessens  nitrogen  excre- 
tion, and  as  it  aids  in  preserving  weight,  and  furthermore  causes  no  putre- 
faction in  the  intestines,  it  is  of  some  value  as  a  food.  The  ingestion  of 
7.5  per  cent,  of  the  total  heat  requirement  of  the  organism  in  the  form  of 
gelatin  spares  23  per  cent,  of  the  body^s  protein.  Thus,  in  a  total  of  2800 
calories  required  by  a  man  of  154  pounds  (Chittenden),  210  calories  in 
gelatin  are  necessary;  i  gram  of  gelatin  contains  4.1  calories,  so  about  50 
grams  of  gelatin  are  required,  or  i^  ounces  (50.0).  The  gelatin  and 
cereal  gruels  approximate  2000  to  2500  calories,  all  that  can  be  digested 
properly.  Gelatin  also  lessens  the  tendency  to  hemorrhage.  It  should 
not  be  given  if  thrombosis  occurs. 

^  Med.  Rec,  June  20,  1908. 
*N.  Y.  Med.  Jour.,  Feb.  i,  1913. 
'  Amer.  Med.,  Oct.,  1910. 


TYPHOID    FEVER^ — PARATYPHOID    FEVER — BRILL's   DISEASE       71I 

Approximately,  i%  ounces  (50.0)  of  gelatin  in  12  ounces  (375  c.c.)  of 
water,  gives  a  1 2  per  cent,  solution.  This  gelatin  solution  can  be  flavored 
with  lemon,  vanilla,  or  iviih  sugar  or  saccharin  and  be  given  in  divided  doses. 
Strained  rice,  barley,  oatmeal  gruels,  and  chicken  broths,  the  sum  total 
not  over  i>2  to  2  quarts  (liters),  are  also  to  be  given  in  divided  doses  eVery 
three  hours,  the  last  feeding  no  later  than  9  p.  m.  This  makes  in  all  about 
2  to  2>^  quarts  (liters)  of.  nourishment.  The  yolks  of  raw  eggs,  3  to  4 
daily,  are  beaten  in  with  the  broths,  and  gruels  and  butter  are  added.  Of 
this  last  a  trifle  under  }.i  ounce  represents  100  calories.  Milk-sugar  repre- 
sents about  1 20  calories  to  the  ounce,  and  it  may  be  added  to  each  feeding 
with  broth  if  it  seems  to  agree.  Feeding  should  begin  about  6  a.  m.,  and 
the  last  nourishment  at  9  p.  m.  (six  feedings  in  all) .  One  should  give  addi- 
tional  doses  of  gelatin  between  the  other  feedings.  Strained  pea  or  strained 
potato  soup  may  be  given  once  daily  in  place  of  one  of  the  gruels. 

For  example  the  following  table  would  give  an  average  diet  of  2000  to ' 
2500  calories  daily.  It  is  noted  below  that  the  cereals  average  about  five 
times  higher  in  calorie  value  than  does  milk.  A  pat  of  butter  may  be 
added  to  the  gruels — occasionally  sugar  of  milk  disagrees.  For  thin  barley 
gruel  use  i  tablespoon  Robinson's  prepared  barley  to  the  pint  of  water, 
and  double  the  quantity  of  flour  for  the  thicker  gruel.  The  same  pro- 
portions may  be  used  for  the  rice  and  oatmeal.  Thinner  the  gruel,  less 
the  calories.     The  six  gruel  feedings  furnish  5  48-60. 

6.00  A.  M.  Barley  gruel,  sugar  milk  3ij  yolk  i  egg,  i  pat  butter,  total  Sviii-x. 
7.30  A.  M.  Gelatin  solution  5iv  (jelly). 

9.00  A.  M.  Chicken  broth  or  occasionally  lamb  broth  5viii-x. 
10.30  A.  M.  Gelatin  sol.  5"  (jelly). 

12.00  M.  Rice  gruel,  sugar  milk  3ij  yolk  i  egg,  i  pat  butter,  total  5viii-x. 
1.30  p.  M.  Gelatin  S'i  (jelly). 

3.00  p.  M.  Barley  gruel,  sugar  milk  3i)  yolk  i  egg,  i  pat  butter,  total  5viii-x. 
4.30  p.  M.  Gelatin  5"  (jelly). 
6.00  p.  M.  Strained  pea  soup  3viii-x. 
7.30  p.  M.  Gelatin  5ii  (jelly). 

9.00  p.  M.  Rice  gruel,  sugar  milk  3i,  yolk  i  egg,  i  pat  of  butter,  total  5viii-x. 
Only  water  after  9  p.  M.  as  the  patient  requires. 

One  should  administer  about  2500  calories  daily  if  there  are  no  diges- 
tive disturbances  and  particularly  no  tympanites,  and  as  low  as  2000  in 
some  cases  or  even  less.  One  should  individualize  in  each  case.  The  gelatin 
is  of  great  value  for  the  reasons  stated.  The  various  foods  are  alternated 
for  variety.  The  patient  is  not  urged  to  eat.  Whenever  the  temperature 
reaches  103 °F.  or  more,  nothing  but  water  is  administered  until  it  falls 
to  below  103 °F.,  say  102.5°.  The  juice  of  several  oranges  is  given  during 
the  day.  When  the  temperature  falls  to  99.5°F.,  the  gruels  are  thickened 
considerably  and  the  yolks  of  raw  eggs  increased  to  5  or  6  daily  or  even  8. 
When  temperature  becomes  normal,  soft-boiled  eggs  and  soft  diet,  but 
no  return  to  full  diet  until  ten  days  have  elapsed. 

At  least  1  to  i^  quarts  (liters)  of  water,  to  which  dilute  sulphuric 
acid,  20  minims  (1.184  c.c.),'  is  added,  are  to  be  drunk  by  the  patient 
during  the  twenty-four  hours  if  no  distention  is  produced.  The  water 
can  be  saved  for  the  night  period  when  thirsty,  9  p.  m.  to  6  a.  m.     Dilute 


7I2  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

nitromuriatlc,  or  dilute  hydrochloric  acid  may  be  substituted  for  the 
dilute  sulphuric  acid. 

For  the  advocates  of  milk,  I  would  state  that  the  sour  milks,  such  as 
matzoon,  bacillac,  fermillac,  koumiss,  kefir,  and  lactone-butter-milk,  are 
preferable  to  plain  milk.  Effervescence  should  be  allowed  to  pass  off 
from  them  before  administering,  and  it  is  preferable  to  dilute  some 
with  lime-water  or  water.  Matzoon  and  the  thicker  sour  milks  should  be 
diluted  one-half  with  plain  water,  or  Vichy  that  has  become  flat,  to  avoid 
distention.  Milk,  if  administered,  should  be  diluted  one-half,  preferably 
with  barley-water  or  rice  gruel.  In  loo  c.c.  of  milk  are  contained  only  64 
calories,  or  640  calories  per  liter;  4  quarts  (liters)  of  undiluted  milk  would 
not  give  more  than  2800  calories  required  for  a  man  weighing  154  pounds. 
The  fallacy  of  pure  milk-diet  is  thus  demonstrated.  Rice,  barley,  and 
oatmeal  average  about  350  calories  per  100.  If  milk  is  given,  its  calorie 
value  and  digestibility  are  increased  by  these  cereals.  About  i}4  quarts 
(liters)  of  milk,  or  sour  milks  thus  diluted,  could  be  given  in  twenty-four 
hours.  I  do  not  advocate  their  use.  Carbonated  waters,,  while  effervesc- 
ing, add  to  distention. 

Bowels. — The  bowels  are  freely  opened  by  calomel,  5  grains  (0.3),  or 
castor  oil,  ij^  ounces  (45.0),  on  the  first  day,  and  thereafter  hot  saline 
enemata,  i}4  liters  (1500  c.c),  at  110°  to  ii5°F.,  or  if  gas,  enteroclysis 
(recurrent),  i  gallon  is  given  A.  m.  and  p.  m.  as  a  routine.  Hemorrhage, 
perforation,  or  appendicitis  are  the  only  contraindications.  There  is  one 
exception  to  this  rule:  gentle  bowel  irrigation  with  a  tube  and  funnel, 
with  hot  normal  saline  solution  at  i20°F.  during  hemorrhage,  lessens  tym- 
panites and  helps  contract  the  vessels.  Performed  by  the  physician,  if 
guarded  by  a  hypodermic  of  morphin,  },i  grain  (0.016),  to  prevent  subse- 
quent peristalsis,  I  believe  the  procedure  to  be  of  value. 

Temperature. — Sponging. — With  proper  diet  and  irrigation  of  the 
bowels,  tub-baths  are  rarely  necessary.  Cold  sponging  with  alcohol  and 
water,  combined  with  friction  when  the  temperature  reaches  102. 5°F.  or 
over,  generally  suffice. 

Strong^  has  secured  reduction  of  temperature  and  relief  of  nervous 
symptoms  by  continuous  irrigation  of  the  bowel  with  cold  normal  salt 
solution  with  the  Kemp  tube,  in  one  case  with  ice-cold  water  for  an  hour 
or  more,  where  baths  failed.  Cold  irrigation  should  be  avoided  if  there  is 
marked  nephritis  or  poor  circulation. 

Baths. — I  am  not  opposed  to  the  Brand  method,  as  a  scientific  procedure 
for  its  additional  effects  on  the  pulse  and  on  elimination.  If  the  friction 
bath  is  given,  it  should  be  started  at  about  9o°F.,  never  given  below  7o°F. 
Often  the  warm  bath  is  preferable.  I  have  used  the  Brand  method 
frequently. 

Improvised  Tub. — One  can  improvise  a  bath-tub,  in  fact,  build  it  about 
the  patient,  by  rolling  up  heavy  blankets,  in  the  shape  of  bolsters,  forming 
the  shape  of  a  bath-tub.  A  rubber  horse-blanket,  or  heavy  rubber  sheet  is 
then  slipped  under  the  patient  and  the  edges  brought  over  the  rolled  blank- 
ets. Water  at  the  desired  temperature  is  poured  gently  over  the  patient, 
friction  being  employed  at  the  same  time.    The  water  is  ultimately 

^Amer.  Med.,  Oct.,  igio. 


TYPHOID   FEVER — PARATYPHOID   FEVER — BRILL's   DISEASE       713 

inopped  up  with  large  sponges,  and  the  patient  dried  in  a  blanket.  The 
head  can  be  flexed  and  lie  on  a  pillow  just  beyond  the  edge  of  the  tub,  the 
shoulders  lying  within  it.  The  feet  can  also  extend  beyond  the  improvised 
tub,  being  wrapped  in  blankets.  This  method  allows  one  to  use  a  short 
improvised  tub  in  the  patient's  bed  and  avoids  practically  all  manipula- 
tion and  lifting. 

The  Nauheim  bath  (Triton  salts),  advocated  by  William  H.  Thomson, 
especially  if  friction  is  combined,  is  superior  to  the  Brand  bath.  In  Fig. 
295  is  a  portable  tub,  weight  5  pounds,  excellent  for  private  work. 

Strychnin,  }io  to  }4o  grain  (0.00108-0.0021),  or  Hoffmann's  anodyne, 
I  dram  (4.0),  may  be  required  in  the  bath.  The  average  duration  of  the 
bath  should  be  twenty  minutes,  longer  if  no  reduction  of  high  temperature 
occurs.     If  the  patient  looks  blue  or  shivers,  he  should  be   removed. 


Fig.  295. — Chambers'  portable  bath-tub. 

Medicinal  Treatment. — Antipyretics  should  be  avoided.  Though 
Chantemesse  has  reported  some  results  from  serum-therapy,  it  is  doubtful 
whether  anything  of  value  has  yet  been  obtained,  though  interesting  data 
have  been  reported  on  the  injection  of  bacterial  vaccines  by  Walters  and 
Eaton.  ^ 

Anders^  believes  vaccine  therapy  should  receive  a  more  extended  trial, 
and  advocates  it  as  a  prophylactic,  during  convalescence,  to  prevent 
relapses,  to  combat  local  infections  from  the  typhoid  bacillus,  and  for  the 
removal  of  typhoid  bacilli  from  the  feces  and  urine.  He  questions  its 
safety  in  the  severe  types.  Recently  some  favorable  results  have  been 
reported  from  the  use  of  sensitized  vaccines.^  I  have  not,  however, 
employed  that  method. 

Bismuth  subnitrate  or  subcarbonate,  in  a  dose  of  15  to  20  grains  (i.o- 

1.3),  combined  with  the  same  quantity  of  saccharated  pepsin,  I  employ 

1  Med.  Rec,  Jan.  16,  1909. 

^  Jour.  Amer.  Med.  Assoc,  Dec.  10,  1910. 

'Jour.  Amer.  Med.  Assoc,  July  24,  1915.     Gay  (Sensitized  Vaccines). 


714 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


every  three  hours,  on  an  average  of  four  doses  a  day.  The  bismuth  helps 
control  the  ulcers.  As  hexamethylenamin  causes  disappearance  of  the 
bacilli  from  the  urine,  it  would  seem  a  logical  remedy.  Hexamethylen- 
amin, 5  to  lo  grains  (0.3-0.6),  given  preferably  with  equal  quantities  of 
sodium  benzoate  in  water.  It  should  be  administered  four  times  a  day 
or  oftener,  from  40  to  60  grains  daily.  I  have  apparently  seen  some 
benefit  in  lessening  the  temperature  and  tympanites  by  this  method. 
Acetozone  (i  :  1000),  given  in  divided  doses,  about  i  to  i^.^  quarts  (liters) 
per  day,  has  been  favorably  reported  in  some  cases;  each  dose  is  flavored 
with  orange  juice. 

Protodysis. — Riesman^  suggests  the  value  of  proctoclysis  in  the  severe 
cases,  as  it  increases  urinary  flow  and  lessens  nervous  symptoms.  As 
an  aid  to  elimination  of  the  toxins,  the  writer  believes  it  may  prove  of 


Fig.  296. — Postural  treatment  for  acute   dilatation   of    stomach    and    intestmes    in 

typhoid  fever. 

value.    It  is  also  useful  when  perforation  and  sepsis  occur  subsequent  to 
operation. 

Tympanites. — Hot  fomentations  and  turpentine  stupes  are  employed. 
The  ice-hag  is  best  in  many  cases.  A  rectal  tube  may  be  inserted,  or  a 
soapsuds  enema  containing  oil  of  turpentine,  i  dram  (4.0),  be  given. 
Spirits  of  turpentine,  10  to  15  minims  (0.592-1. 184),  can  be  given  three  or 
four  times  a  day,  or  resin  turpentine,  3  grains  (0.194),  four  times  a  day, 
or  oil  of  cinnamon,  3  to  5  minims  (0.178-0.296),  every  two  hours.  Char- 
coal, 5  grains  (0.3),  bismuth  subnitrate,  15  grains  (i.o),  beta-naphthol, 
3  grains  (0.194),  or  ichthalbin,  ichthoform,  or  formidin,  5  grains  (0.3), 
every  three  to  four  hours,  may  be  substituted.  Acute  distention  is  re- 
lieved by  enteroclysis.  As  acute  dilatation  of  the  stomach  is  often  asso- 
ciated, lavage  is  also  of  value.  This  is  especially  true,  in  distention  with 
active  hemorrhage.'^ 

^  Jour.  Amer.  Med.  Assoc,  Jan.  29,  1910. 

2  With  general  distention,  lavage  should  be  employed  in  addition  to  enteroclysis. 


TYPHOID   FEVER — PARATYPHOID   FEVER — ^BRILL's   DISEASE       715 

A  thorough  bowel  action  should  at  once  be  secured  if  there  is  no  hemor- 
rhage. Eserin,  }^o  grain  (0,00108)  by  hypodermic,  may  be  of  value  for 
this  purpose.  Several  doses  may  be  required  at  two-hour  intervals,  two 
or  three  in  all,  each  guarded  with  strychnin,  ^q  grain. 

As  I  order  magnesium  sulphate  or  citrate,  i  dram  (4.0)  every  second 
or  third  day,  in  addition  to  the  rectal  irrigation,  tympanites  is  rare. 

In  Fig.  296  is  illustrated  the  correct  position  to  relieve  pressure  from 
tympanites  (gastro-intestinal  distention)  pulse  and  respiration  lessened  20 
points  as  a  result,  and  the  tympanitic  area  in  the  thorax  diminished  4 
inches.  If  the  dilatation  is  of  the  stomach  alone,  or  gastro-duodenal, 
then  the  right  side  or  the  belly  position  should  be  assumed. 

Diarrhea. — The  bismuth  preparations,  chalk,  and  occasionally  a  little 
opium  (see  chapter  on  Diarrhea),  rtiay  be  required,  and  the  enemata 
should  be  stopped  for  twenty-four  hours,  if  the  movements  are  excessive. 

Consiipation  does  not  occur  when  the  methods  described  are  employed. 

Hemorrhage. — Morphin,  }i  grain  (0.016),  by  hypodermic,  is  indicated, 
and  the  ice-bag  should  be  immediately  applied.  Then  lactate  of  calcium, 
15  grains  (i.o),  is  given  with  2  to  4  drams  (60.0-125.0)  of  5  to  10  per  cent, 
gelatin  solution;  chlorid  of  calcium,  10  grains  (0.6),  may  be  substituted. 
Thereafter,  lactate  of  calcium,  10  grains  (0.6),  with  2  ounces  (60.0)  of  10 
per  cent,  gelatin  every  four  hours.  Ernutin,  5  minims  (0.296),  may  be 
given  by  hypodermic. 

William  H.  Thomson  recommends  the  following: 

R.  Pulv.  opii  1  . .  /     V 

ArgentinitratisJ  aa  gr.  v  (0.3); 

Resin  turpentine 5ij  (8.0); 

Liquor  potassii 3  J  (4-°)  5 

Licorice  pulv q.  s.  — M. 

Divide  into  60  pills. 
Sig. — ^Two  pills  every  four  hours.     They  may  be  given  for  a  few  doses  at 

two-hour  intervals. 

Large  doses  of  opium  should  be  avoided,  as  they  obscure  symptoms. 

Adrenalin  (i  :  1000),  5  to  10  minims  (0.296-0.592),  has  been  advocated 
by  hypodermic,  but  it  may  increase  pulse-tension  too  markedly.  The 
administration  of  human  serum  may  be  indicated  in  severe  hemorrhage. 

Hypodermoclysis,  preferably  in  the  iliolumbar  region,  as  in  Fig.  297, 
with  normal  salt  solution,  may  be  required,  or  even  saline  or  mediate 
infusion. 

At  any  time,  on  the  appearance  of  blood  in  the  stool  or  of  suspected 
hemorrhage,  stop  enteroclysis  and  baths  (if  they  are  being  given)  at  once. 

Perforation  and  Peritonitis. — Early  operation  is  indicated. 

Heart  5/fww/aw/5.-i-Strychnin  sulphate,  Y^q  to  yia  grain  (0.00108- 
0.0021),  every  three  or  four  hours  by  hypodermic,  or, 

I^.  Pulv.  camphor gr.  viiss  (0.5), 

Sterile  almond  oil ITlxx  (1.184). — M. 

Sig. — One  dose  every  four  to  six  hours  by  hypodermic  may  be  required, 
especially  if  there  are  cardiac  complications. 

Aromatic  spirits  of  ammonia  or  Hoffmann's  anodyne,  in  i-dram  (4.0) 
doses,  are  useful  in  emergency.  I  have  employed  camphor  gr.  40-60 
dailv  in  divided  doses  for  a  week. 


7i6 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


Cafifein  citrate,  i  to  2  grains  (0.065—0.13)  every  three  or  four  hours,  is 
of  service;  or  give  caffein  by  hypodermic  in  the  form  of  sodii  salicylate 
of  cafifein,  or  sodium  benzoate  of  cafifein.  Camphor  in  sterile  almond  oil 
— gr.  V  camphor  in  lUxx  almond  oil  by  hypodermic — given  every  hour  or 
two  if  necessary,  is  of  great  value.  For  pneumonia  complicating  typhoid, 
80  to  100  grains  daily  by  hypodermic  as  first  suggested  by  Seibert  is  useful. 
The  writer  prefers  to  subdivide  into  four  hypodermics,  daily  as  causing 
less  local  pain. 

Some  advise  alcohol,  8  to  12  ounces  (250-375  c.c),  in  divided  doses, 
but,  like  Seibert,  I  have  not  found  it  necessary.  Large  doses  of  tincture 
of  digitalis,  or  digitalone,  5  to  15  drops  every  four  hours,  may  be  added  in 
the  case  of  alcoholics.  Careful  stimulation  with  drugs,  I  believe,  causes 
less  strain  on  the  kidnevs. 


Fig.  297. — ^Hypodermoclysis  in  the  iliolumbar  region. 

The  former  views  as  to  the  value  of  alcohol  as  a  food,  or  its  power  to 
increase  the  capacity  for  work,  seem,  by  scientific  research,  to  be  pretty 
thoroughly  exploded.  Its  use  in  the  arctic  regions,  where  food  of  high 
calorie  value  is  at  a  premium,  has  been  found  to  be  deleterious.  In  sud- 
den emergency,  as  a  heart  stimulant,  it  is  of  value,  but  its  prolonged  use 
as  a  circulatory  tonic  has  been  shown  to  be  harmful.  Proper  individual 
dosage  is  difficult  to  estimate,  and  the  strain  on  the  already  damaged 
eliminating  organs  in  typhoid  fever  is  severe. 

Professor  Frederick  S.  Lee,^  in  a  series  of  experiments,  finds  that  in 
small  quantity  ethyl  alcohol  does  not  appear  to  exert  any  action  on  frog's 
muscle;  while  in  medium  quantity  it  increases  the  rapidity  of  contraction 
and  relaxation,  and  increases  the  working  time,  i.e.,  delays  fatigue.     In 

^  The  Action  of  Alcohol  on  Muscles,   Amer.  Jour,  of  Physiol.,  1902,  viii,  p.  61. 


TYPHOID   FEVER — PARATYPHOID    FEVER — ^BRILL'S   DISEASE       717 

large  quantities  it  exerts  an  unfavorable  action,  the  reverse  of  that  caused 
by  medium  quantities  of  the  drug,  i.e.,  it  hastens  fatigue.  The  advocates 
of  the  use  of  alcohol  in  typhoid  fever  administer  it  in  considerable  quanti- 
ties. Moreover,  the  author  wishes  to  call  to  the  reader's  attention  that 
alcohol  interferes  with  the  oxidation  process. 

For  Nervous  Symptoms. — Warm  or  cool  packs  with  ice-bag  to  the  head, 
and  at  times  bromids  or  opiates,  are  indicated. 

For  Headache. — Cold  applications  and  the  bromids  are  useful. 

For  Sleeplessness. — Sulphonal,  trional,  or  veronal,  lo  grains  (0.6). 

BaciUtiria. — Hexamethylenamin  and  benzoate  of  soda,  of  each  10 
grains  (0.6),  every  three  hours  by  mouth,  or  by  enema  if  nausea,  should 
be  given  in  colon  bacillus  infection. 

Care  should  be  taken  to  guard  against  bed-sores.  Tender  toes  should 
be  protected  from  the  weight  of  the  sheets,  and  hyperextension  of  the  feet 
should  be  avoided.  In  some  cases  a  water-  or  air-bed  or  an  old  sheepskin 
spread  under  the  patient,  as  suggested  by  Thomson,  may  be  required. 

For  Renal  Insufficiency. — Cream  of  tartar  lemonade:  Cream  of  tartar, 
I  dram  (4.0);  juice  of  2  lemons;  saccharin,  i  grain  (0.063);  water,  i  quart 
(liter).  Drink  in  divided  doses  during  the  day.  Recurrent  enteroclysis 
with  normal  saline  solution  at  1 20°F.  and  proctoclysis  are  useful.  Caffein 
citrate,  5  grains  (0.3),  t.i.d.,  is  of  value,  or  an  equivalent  of  a  soluble 
preparation  of  caflfein  by  hypodermic.  Hypodermoclysis  may  be  neces- 
ary.  Recurrent  enteroclysis  several  times  daily  at  i2o°F.  is  the  best 
method. 

Colitis  should  receive  treatment  as  described  in  that  chapter.  The  late 
Francis  Delafield^  has  secured  results  in  membranous  colitis  by  irrigation 
with  2  quarts  (liters)  of  bichlorid  of  mercury  (i  :  10,000)  with  the  recurrent 
tube.     It  should  only  be  used  with  such. 

Complications  should  receive  appropriate  treatment. 

Convalescence. — It  is  usually  preferable  to  have  a  normal  temperature 
for  a  week  before  commencing  with  solid  food.  Soft-boiled  eggs,  milk- 
toast,  jellies,  and  a  little  scraped  beef  should  be  first  tried. 

In  some  prolonged  cases,  with  temperatures  of  99°  to  ioo°F.,  cautious 
feeding  may  be  attempted  with  the  above  materials.  I  have  seen  the 
temperature  fall  as  a  result. 

Bacilluria  I  believe  a  frequent  cause  of  slight  persistent  temperature. 
This  should  receive  treatment  as  already  described.  The  patient  should 
first  sit  up  for  a  brief  period  about  the  tenth  day  of  normal  temperature. 

During  convalescence  the  urine  should  be  particularly  examined  for 
colon  and  typhoid  bacilli,  and  hexamethylenamin,  10  grains,  with  an  equal 
quantity  of  sodium  benzoate,  should  be  given  three  or  four  times  daily. 
The  urine  should  be  free  from  typhoid  bacilli  before  discharging  the  patient. 

Typhoid  Carriers. — Some  of  these  are  convalescents  from  the  disease, 
while  others  have  not  had  typhoid,  but  have  been  in  contact  with  cases. 
These  cases  should  be  kept  isolated  and  hexamethylenamin  gr.  60  to  80 
combined  with  equal  quantities  of  sodium  benzoate  aa  gr.  x  per  dose,  in 
twenty-four  hours  should  be  given  until  the  urine  is  free  from  typhoid 
bacilli.  The  patient  should  be  carefully  examined  subsequently  to  see 
'  Enteroclysis,  Hypodermoclysis,  and  Infusion  (Kemp). 


7l8  DISEASES  or  THE   STOMACH  AND   INTESTINES 

that  there  is  no  reappearance  of  the  bacilli.  In  obstinate  cases  the  use  of 
autogenous  vaccines  up  to  1,000,000,000  at  an  injection  has  proved  success- 
ful. The  importance  of  the  typhoid  carrier  is  shown  by  the  fact  that  they 
are  a  potent  source  of  infection  to  others.  "  Typhoid  Mary  "  is  a  well- 
known  classical  case/  having  again  recently  been  responsible  for  an  epidemic 
of  typhoid  at  the  Sloane  Maternity  Hospital.  Park^  holds  that  about  2 
per  cent,  of  all  typhoid  cases  become  carriers. 

The  gall-bladder  harbors  the  bacilli,  which  are  excreted  in  the  feces, 
though  they  may  be  found  in  the  saliva  and  two  cases  have  been  reported 
of  typhoid  prostatitis  and  seminal  vesiculitis. 

Leary^  reports  two  cases  of  removal  of  the  gall-bladder  and  entire  cystic 
duct  for  the  cure  of  typhoid  carriers.  This  procedure  would  be  justifiable, 
after  failure  of  the  vaccine  and  hexamethylenamin  treatment. 

PARATYPHOID  FEVER 

This  is  a  term  applied  to  a  group  of  diseases  which,  in  their  clinical 
course,  may  somewhat  resemble  t)q)hoid  fever. 

Etiology. — Paratyphoid  fever  is  caused  by  the  microorganisms  known 
as  Bacillus  para  typhosus  A  and  Bacillus  para  typhosus  B,  which  differ  in 
their  agglutination  reactions,  that  is,  the  blood-serum  of  the  patient 
agglutinates  the  cultures  of  the  causative  organism.  The  organisms  are 
isolated  from  the  blood,  lu-ine,  or  feces.  They  are  intermediate  between 
the  Bacillus  typhosus  and  the  Bacillus  coli.  In  the  epidemics  abroad. 
Bacillus  paratyphoid  B  is  recovered  from  much  more  frequently  than  the 
paratyphoid  A,  which  seems  more  common  in  America.*  Recently,  how- 
ever, in  Virginia,  an  epidemic  from  paratyphoid  B,  in  all  35  cases,  has 
been  reported  by  Hoskins.^  The  Bacillus  paratyphosus  B  also  has  an 
etiologic  relationship  to  bacterial  food  (meat)  poisoning,  and  the  question 
has  arisen  whether  there  is  a  common  infectious  disease,  assuming  an 
acute  form  as  meat-poisoning  and  a  subacute  form  as  paratyphoid  fever. 
The  Germans,  in  fact,  assert  that  meat,  particularly  beef,  is  the  habitat 
of  the  germ  Bacillus  paratyphoid  B,  and  that  the  fever  is  produced  by 
toxins  generated  by  these  bacilli  in  ingested  beef.  They  describe  one 
variety  resembling  ptomain-poisoning,  occurring  with  prodromal  symp- 
toms, such  as  bronchitis,  nose-bleed,  headache,  malaise,  and  abdominal 
tenderness.  There  is  at  first  a  high  temperature,  which  subsides  after 
the  administration  of  calomel.  Subsequently,  the  temperature  curve  is. 
very  little  above  normal,  though  tympanites,  gurgling  in  the  right  iliac 
fossa,  rose-spots,  enlarged  spleen,  abdominal  soreness,  and  increased  pulse- 
rate  are  present.     This  variety  lasts  seven  to  eleven  days. 

A  second  variety  is  characterized  by  a  higher  temperature  and  symp- 
toms simulating  typhoid  fever,  and  lasts  eleven  to  fourteen  days,  and  in 
several  cases  three  weeks.     Proescher^  and  Roddy  have  conducted  some 

^American  Medicine,  March,  1915. 

*  Journal  A.  M.  A.,  Sept.  19,  1908. 
'  Jour.  A.  M.  A.,  June  26,  1913. 

*  H.  Fox,  Univ.  Penna.  Med.  Bull.,  1905,  vol.  xviii;  and  Proescher  and  Roody, 
Jour.  Amer.  Med.  Assoc.,  Feb.  6,  1909. 

*  Jour.  Amer.  Med.  Assoc.,  March  19,  19 10. 

•  Archiv  of  Int.  Med.,  March,  1910. 


TYPHOID   FEVER — PARATYPHOID    FEVER — BRILL's   DISEASE       719 

interesting  investigations  on  the  parat)q)hoid  A  and  B  bacilli.  These 
types  of  paratyphoid  bacilli  can  readily  be  differentiated  from  the  Bacillus 
t)^hosus  and  the  Bacillus  coli. 

Mode  of  Infection. — Ingestion  of  meat  containing  the  germ  of  the  Bacil- 
lus paratyphoid  B  is  claimed  as  a  cause  of  this  type,  while  the  usual  meth- 
ods of  conveyance  are  the  same  as  of  typhoid  fever,  such  as  the  food, 
water,  by  the  fomites,  urine,  fingers,  and  flies. 

Pathology. — There  are  splenic  enlargement  and  intestinal  ulcerations, 
resembling  those  of  dysentery  rather  than  of  typhoid  fever.  There  are 
involvement  of  the  solitary  and  agminated  follicles  and  of  the  mesenteric 
glands. 

Incubation. — The  incubation  is  generally  shorter  than  that  of  typhoid, 
though  in  Hoskins'  cases  it  averaged  in  50  per  cent,  nine  to  eleven  days. 
The  prodromal  symptoms  are  languor,  headache,  torpor,  and,  in  some 
cases,  nose-bleed  and  muscular  pains.  There  may  be  discomfort  in  the 
abdomen  and  constipation,  though  occasionally  a  diarrhea.  The  head- 
ache is  often  quite  severe,  and  the  prodromata  are  usually  shorter  and 
more  sudden  than  with  typhoid.  There  is  bronchitis  in  some  cases,  com- 
ing on  shortly,  the  headache  is  constant,  and  some  chilliness  is  complained 
of  in  some  cases,  particularly  in  the  extremities.  The  temperature  fre- 
quently rises  more  rapidly  than  in  typhoid,  at  times  there  'being  a  high 
initial  temperature,  even  to  io4°F.  The  morning  remissions  are  more 
marked  than  in  typhoid  fever.  Paul*  reports,  in  fact,  a  series  of  cases  in 
which  there  was  a  daily  remission  nearly  to  normal.  The  pulse  is  rapid, 
120  or  more,  but  there  is  usually  no  dicrotism.  Delirium  rarely  occurs. 
Nausea  is  frequently  present,  but  vomiting  is  not  very  frequent.  Tym- 
panites is  frequently  present,  though  not  as  marked  as  in  typhoid.  There 
may  be  abdominal  pains  in  the  lower  abdomen,  though  some  cases  are 
reported  of  severe  gastric  pain.  Constipation  is  the  rule,  though  diarrhea 
sometimes  occurs.  In  Hoskins'  cases  the  stools  were  at  first  normal,  later, 
green  tinted  with  yellow,  and  later,  watery,  with  the  peculiar  tint  noted. 
The  urine  is  scanty  and  high-colored,  with,  at  times,  albumin  and  casts. 
Intestinal  hemorrhage  may  sometimes  occur,  but  it  is  not  as  severe  as 
with  typhoid,  and  is  usually  not  recurrent.  Perforation  has  not  been 
reported.  Bronchitis,  as  noted,  is  quite  frequent.  The  tongue  becomes 
thickly  coated,  particularly  toward  the  center,  and  the  edges  may  remain 
red  and  granular.  The  tongue  is  moist  and  does  not  dry  and  crack  as 
with  typhoid,  and  there  are  no  sordes.  The  spleen  is  enlarged,  but  gener- 
ally not  as  markedly  as  with  typhoid.  In  many  cases  there  are  severe 
pains  in  the  muscles  and  nerves.  The  skin  is  at  first  dry,  but  later  becomes 
moist.  Rose-spots  appear  on  the  third  or  fourth  day,  and  may  be  seen  in 
successive  crops  over  the  abdomen,  chest,  and  back.  In  Hoskins'  cases 
there  was  dilatation  of  the  pupils  which  persisted  throughout  the  disease. 
In  his  cases  also,  day  dreaming,  illusions  with  no  delirium,  were  reported 
in  25  per  cent.,  and  most  of  his  patients  were  children. 

Some  of  the  cases  of  paratyphoid  infection,  as  already  noted,  are  more 
of  a  ptomain  type,  a  high  initial  rise  of  temperature  with  nausea  and 

*  N.  Y.  Med.  Jour.,  Oct.  22,  1910. 


720  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

vomiting,  with  a  rapid  subsidence  of  temperature  after  the  administration 
of  calomel. 

Course. — The  course  of  paratyphoid  is  more  frequently  rather  short, 
the  highest  temperature  being  reached  on  the  third  or  fourth  day,  remain- 
ing high  for  three  or  four  days,  and  then  abating  by  lysis.  It  may  occa- 
sionally be  prolonged,  though  usually  it  is  much  shorter  than  typhoid,  and 
relapses  are  rather  rare. 

Complications. — Bronchitis  often  accompanies  it.  Neuritis,  nephritis, 
and  cardiac  disease  are  not  as  liable  as  with  enteric  fever.  Intestinal 
hemorrhage  is  quite  rare  and  never  alarming.  Perforation  has  never 
occurred.  Parotiditis,  arthrititis,  otitis,  and  osteomyelitis  have  been 
reported. 

Diagnosis. — The  onset  of  paratyphoid  fever  is  more  abrupt,  the  initial 
headache  is  more  severe,  the  temperature  rises  more  rapidly,  the  daily 
remissions  are  more  marked,  the  tongue  remains  moist,  there  are  no  sordes, 
and  intestinal  hemorrhage  is  not  frequent  and  is  not  apt  to  recur.  Per- 
foration has  never  been  reported.  The  Widal  reaction  is  absent.  The 
specific  agglutination  reactions  occur  to  Bacillus  paratyphoid  A  or  B,  and 
the  causative  microorganisms  can  be  cultivated  from  the  feces,  urine, 
blood,  and  from  the  rose-spots.  These  all  serve  to  differentiate  from  ty- 
phoid fever. 

With  Brill's  disease  the  cultures  from  the  blood  show  bacilli-type 
exanthematici  and  not  typhoid  bacilli.  Widal  reaction  is  negative.  The 
type  of  fever  is  peculiar.  There  is  no  intestinal  hemorrhage  and  rapid 
convalescence  occurs. 

Prognosis. — Most  patients  recover,  though  a  fatal  result  may  occur. 

Treatment. — This  is  essentially  the  same  as  for  typ/toid  fever.  The  same 
precautions  should  be  taken  regarding  safe-guarding  the  urine,  feces,  etc. 
Hexamethylenamin,  lo  grains  (0.6),  with  benzoate  soda,  10  grains  (0.6), 
should  be  given  four  or  five  times  a  day  to  disinfect  the  blood.  Autog- 
enous vaccines  may  be  employed,  of  the  specific  bacilli  found  in  each 
case. 

MILD  ENDEMIC  TYPHUS,  OR  BRILL'S  DISEASE 

Definition. — This  is  an  acute  infectious  disease,  a  mild  endemic  typhus, 
characterized  by  a  short  incubation  period,  a  period  of  continuous  fever, 
intense  headache,  apathy,  and  prostration,  a  profuse  and  extensive 
maculopapular  eruption,  the  fever  ceasing  at  the  end  of  between  one  and 
two  weeks,  either  by  crisis  or  lysis. 

History. — The  attention  of  the  medical  profession  was  first  called  to 
this  disease  by  Nathan  E.  Brill, ^  who  demonstrated  that  it  possessed 
peculiar  characteristics  which  differentiated  it  from  typhoid  and  para- 
typhoid fever.  He  has  made  a  study  of  255  cases.^  Ziegel^  reports  three 
cases.  Anderson^  and  Goldberger  have  experimentally  demonstrated  its 
identity  with  typhus  fever. 

^  N.  Y.  Med.  Jour.,  Jan.  8  and  15,  1898;  Amer.  Jour.  Med.  Sci.,  April,  1910. 

'  Amer.  Jour.  Med.  Sci.,  Aug.,  igii. 

'Med.  Rec,  June  25,  1910. 

*  N.  Y.  Med.  Jour.,  May  11,  1Q12. 


TYPHOID    FEVER PARATYPHOID    FEVER BRILL  S    DISEASE       72 1 

Incubation. — This  varies  from  a  sudden  onset  to  fourteen  days. 

Etiology. — The  disease  is  infectious,  a  mild  endemic  typhus.  The 
bacillus  typho-exan thematic!  discovered  by  H.  Plotz  is  responsible.  In 
Brill's  255  cases  members  of  the  same  family  or  occupants  of  the  same 
house  were  never  attacked.  W.  Coleman,  however,  has  observed  four 
cases  from  the  same  family  and  household.  M.  Nicoll^  reports  four 
cases  in  one  family,  two  of  them  young  children.  Brill,^  however,  reports 
a  fatal  case.  Anderson  estimates  that  in  1912,  there  were  72  cases  in  New 
York  City,  and  cases  were  reported  in  Boston,  Baltimore,  Philadelphia,  and 
Chicago. 

Males  are  more  commonly  affected  than  females,  and  it  is  more  fre- . 
quent  between  twenty  and  forty  years.  The  largest  number  of  cases 
occur  in  summer. 

Method  of  Transmission. — Head  lice  and  body  lice  are  the  chief  source. 

Symptoms. — After  a  few  days,  marked  by  malaise,  loss  of  appetite, 
nausea,  and  slight  headache,  the  invasion  is  usually  abrupt,  ushered  in 
with  a  chill  or  chilly  sensations,  followed  by  severe  headache  and  a  high 
fever.  Occasionally  there  is  vomiting,  usually  general  pains,  or  pains  in 
the  back.  The  headache  becomes  intense  and  there  is  marked  prostra- 
tion, with  a  rising  temperature.  The  temperature  curve  reaches  its  height 
in  two  to  three  days,  and,  with  but  slight  daily  remissions,  remains  con- 
stant. The  temperature  is  shown  in  Figs.  298  and  299.  The  eyes  are  dull 
and  suffused  and  the  face  flushed.  The  patient  is  dull  and  prefers  to  be 
let  alone.  The  tongue  is  coated  and  moist.  On  the  fifth  or.  sixth  day 
an  eruption  appears  on  the  abdomen  and  back,  and  spreads  rapidly  to  the 
chest  and  to  the  extremities.  It  is  sometimes  seen  on  the  neck,  palms, 
and  soles  in  addition.  The  rash  is  profuse  but  discrete,  and  sometimes 
small  patches  are  formed.  It  is  maculopapular  in  character,  dull  red  in 
color,  slightly  raised,  and  the  spots  usually  have  an  oval  indistinct  outline. 
They  fade  somewhat  under  pressure,  but  do  not  disappear  entirely.  At 
times  hemorrhagic  spots  are  interspersed  with  the  other  lesions. 

The  eruption  fades  rapidly  at  the  time  of  defervescence,  but  its  remains 
are  seen  for  some  days  as  brownish  stains. 

The  bowels  are  obstinately  constipated.  The  spleen  is  frequently 
enlarged.  Herpes  labialis  is  sometimes  present.  Leukopenia  is  excep- 
tional; at  times  there  are  9000  to  11,000  leukocytes,  though  often  the 
absolute  and  differential  leukocyte  count  is  normal  unless  there  are  com- 
plications. About  the  twelfth  to  fourteenth  day  the  fever  and  other  symp- 
toms disappear  and  rapid  convalescence  follows. 

Complications. — Bronchitis  develops  early  ih  some  cases.  Broncho- 
pneumonia is  rare,  in  which  event  marked  leukocytosis  occurs.  Meningis- 
mus,  rigidity  of  the  neck,  contracted  pupils,  and  bilateral  Kernig's  sign 
are  sometimes  present.  Phlebitis  has  been  observed  once  and  otitis 
media  once. 

Diagnosis. — The  absence  of  the  Widal  reaction  and  negative  blood, 
stool,    and    urine    cultures    as    to    typhoid,  paratyphoid,   colon   bacilli 

^  Amer.  Jour.  Med.  Sci.,  Aug.,  1911. 
*  Journal  A.  M.  A.,  Aug.  17,  1912. 
^N.  Y.  Med.  Jour.,  Dec.  ii,  1915. 
46 


722 


DISEASES    OF   THE    STOMACH    AND   INTESTINES 


or  intermediate  infections,  with  presence  of  positive  bacillus  typhosus  of 
Plotz,  give  the  diagnosis.     Leukopenia,  which  occurs  in  typhoid,  is  absent 


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S  i  "8  i  "I  ^  s  I  s  8  s> 


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in  Brill's  disease.     The  character  of  the  onset,  absence  of  intestinal  hem- 
orrhage, type  of  fever,  character  of  the  eruption,  and  rapid  convalescence 


TYPHOID   FEVER — PARATYPHOID   FEVER — BRILL.'s   DISEASE       723 

exclude  typhoid  fever.  Its  apparent  non-communicability,  the  uniformity 
of  its  type,  and  usually  the  absence  of  fatal  cases  seem  to  exclude  t)T)hus 
fever,  though  now  proven  to  be  a  mild  form  of  such. 

The  occasional  meningismus  which  occurs  suggests  meningitis,  but 
lumbar  puncture  shows  its  absence. 

Influenza  can  be  excluded  by  the  history  and  by  the  speedy  recovery 
from  Brill's  disease. 

Prognosis. — The  total  mortality  of  this  mild  endemic  type  in  the  U.  S. 
is  estimated  at  not  over  1  per  cent. 

Treatment. — As  a  matter  of  precaution,  the  stools,  urine,  beds, 
bedding,  etc.,  are  disinfected,  clothing  steamed,  and  the  same  prophylactic 
measures  taken  as  with  typhoid  fever.  Hair  should  be  shaved  and  para- 
siticides applied  auch  as  petrol,  benzol,  xylol,  turpentine  or  paraffin  oil. 
The  last  two  or  petrol  or  naphthalin  especially  destroy  the  "  nits. "  Spong- 
ing or  friction  baths  should  be  employed  to  relieve  temperature.  Plenty 
of  water  should  be  given  and  the  diet  should  be  fluid,  preferably  strained 
broths  and  gruels.  One  may  employ  sour  milks,  such  as  matzoon  with 
Vichy,  koumiss,  lactone-buttermilk,  bacillac,  etc.,  or  equal  parts  of  milk 
and  lime-water.  The  bowels  should  be  opened  freely  with  calomel,  5 
grains  (0.3),  and  a  daily  movement  should  be  secured.  For  headache, 
cold  applications  and  the  bromids  are  indicated. 

For  the  muscular  pains  the  following  is  of  value: 

I^.  Phenacetin gr.  iij; 

Acetanilid gr-  ij; 

Caffein  citrate ' gr.  H- — M. 

Sig. — One  capsule  three  or  four  times  a  day. 

Stimulation  with  strychnine  and  camphor  as  required.  Immuniza- 
tion against  typhus  should  be  performed  to  protect  those  exposed  to 
an  epidemic  or  when  the  disease  is  prevalent. 


CHAPTER  XXVIII 

INTESTINAL  HEMORRHAGE;  INTESTINAL  ULCERS ;  DUODENAL 

ULCER ;  DISEASES  OF  THE  BLOOD-VESSELS  (EMOBLISM 

AND  THROMBOSIS) 

INTESTINAL  HEMORRHAGE 

It  would  seem  advisable  to  refer  to  the  various  causes  of  intestinal 
hemorrhage  for  the  purpose  of  diagnosis.  Among  such  are  dysentery, 
typhoid,  yellow  fever,  malarial  poisoning,  ulceration  from  various  causes, 
cancer,  scurvy,  purpura,  traumatism,  volvulus,  intussusception  after  re- 
duction of  a  strangulated  hernia,  excessive  use  of  laxatives,  hemorrhoids, 
injury  (traumatism),  venous  hyperemia  of  the  intestines  due  to  diseases 
of  the  heart  or  lungs,  stasis  or  obstruction  of  the  portal  system,  such  as  cir- 
rhosis of  the  liver,  injury  from  dried  scybalae,  ankylostoma,  isolated  venous 
varicosities,  arterial  aneurysms  of  the  intestinal  wall,  aneurysms  in  adja- 
cent arteries,  as  of  the  hepatic,  from  which  blood  may  enter  the  bile-pas- 
sages and  be  passed  by  the  bowel.  One  case  is  reported  resulting  from 
punctures  in  the  intestines  made  by  a  male  round  worm. 

A  peculiar  type  of  enterorrhagia  occurs  with  no  anatomic  changes, 
but  there  is  probably  an  alteration  in  the  walls  of  the  blood-vessels.  Thus, 
intestinal  hemorrhages  have  occurred  in  phthisis  when  there  were  no  ulcers. 

Intestinal  hemorrhages  in  pernicious  anemia,  leukemia,  scurvy,  morbus 
maculosus,  septicemia,  icterus,  phosphorus-poisoning,  intermittent  fever, 
and  erysipelas  probably  belong  to  this  class.  Amyloid  degeneration  may 
be  complicated  by  intestinal  hemorrhages.  Some  believe  vicarious  hem- 
orrhage may  take  the  place  of  menstruation. 

There  may  be  collapse,  with  all  the  symptoms  of  internal  hemorrhage, 
and  blood  may  or  may  not  pass  from  the  rectum.  The  blood  may  be 
bright  red,  brown,  or  like  coffe-grounds. 

No  visible  blood  may  appear  in  the  stools,  and  it  may  be  detected  only 
by  tests  for  occult  blood. 

Microscopic  examination  may  show  the  presence  of  red  blood-corpus- 
cles and  hematin. 

Treatment. — The  immediate  hemorrhage  should  be  treated  as  de- 
scribed under  Hemorrhage  in  Typhoid,  and  the  cause  should  be  deter- 
mined and  treated. 

ULCERS  OF  THE  INTESTINES 

Duodenal  Ulcers 

In  considering  the  subject  of  duodenal  ulcers,  it  is  necessary  to  briefly 
classify  the  various  types  which  occur.     They  are  as  follows: 

I.  Simple  duodenal  ulcer,  or  peptic  ulcer  of  the  duodenum,  or  chronic 
duodenal  ulcer  (Moynihan). 

724 


SIMPLE   DUODENAL   ULCER  725 

2.  Duodenal  ulcer  due  to  burns  or  scalds. 

3.  Duodenal  ulcer  due  to  the  uremic  condition. 

4.  Tuberculous  ulcer  of  the  duodenum. 

5.  Duodenal  ulcer  due  to  Melaena  neonatorum  and  to  purpura. 

6.  Embolic  or  thrombotic  ulcer  of  the  duodenum,  as  with  appendicitis. 

7.  Amyloid  ulcer  of  the  duodenum. 

8.  Duodenal  ulcers  in  infectious  diseases,  as  in  pneumonia  (rare), 
typhoid,  erysipelas,  and  varioloid. 

9.  Duodenal  ulcers  have  been  reported  in  isolated  cases  of  acute 
pemphigus  and  pellagra. 

10.  SyphiUtic  gummatous  ulcer  at  the  pyloric  ring,  involving  the  stom- 
ach, or  duodenum,  or  both. 

SIMPLE  DUODENAL  ULCER 

{Synonyms. — Duodenal  Ulcer;  Ulcus  Duodeni  Pepticum — Leube;  Round  or  Perforating 
Ulcer;  Chronic  Duodenal  Ulcer — Moynihan) 

The  earliest  mention  of  duodenal  ulcer  occurs  in  the  London  Medico- 
Chirurgical  Transactions  of  1817,  vol.  viii,  p.  232. 

The  condition  is  characterized  by  a  defect  of  the  mucous  membrane 
of  the  duodenum,  usually  tending  to  run  a  protracted  course,  though  in 
some  instances  it  may  be  acute.  Mayo^  believes,  however,  that  acute 
ulcers  are  usually  toxic.  One  may  say,  in  general,  that  duodenal  ulcer 
presents  in  many  cases  the  appearance  and  characteristics  of  ulcer  of  the 
stomach,  particularly  when  found  on  the  posterior  wall. 

When  the  ulcer  is  crater-like  on  the  anterior  wall  of  the  duodenum, 
there  is  a  localized  mass  over  the  site  of  the  ulcer.  Wm.  Mayo^  finds 
that  in  many  cases  no  crater  is  found  in  the  mucosa,  but  rather  a  dis- 
colored moth-eaten  patch  in  whose  center  there  is  a  dimple-like  ulcer,  and 
outside  of  this,  induration. 

Etiology. — The  cause  is  generally  believed  to  be  the  action  of  the  acid 
gastric  juice  upon  the  mucous  membrane  of  the  duodenum,  whose  nutri- 
tion and  vitality  have  previously  been  impaired  as  a  result  of  circulatory 
derangement.  Chlorosis  seems  to  play  no  part  in  its  production,  Fried- 
man claiming  that  polycythemia  or  polyglobuHa  and  eosinopenia  occur 
with  non-hemorrhagic  duodenal  ulcer. 

Codman^  advances  the  theory  that  more  or  less  obstruction  is  produced 
in  some  cases  by  the  pressure  of  the  superior  mesenteric  artery  on  the  duo- 
denum, and  as  a  result  the  secretions  of  the  pancreas  and  liver  may  at 
times  be  thrown  backward  on  the  first  pari  of  the  duodenum,  which  is 
unfitted  to  withstand  the  long-continued  action  of  these  secretions,  since 
the  mucosa  is  histologically  and  developmentally  different  from  the  rest  of 
the  duodenum,  and  is  more  closely  allied  to  that  of  the  stomach. 

The  author  believes  that  if  pressure  obstruction  from  the  superior 
mesenteric  artery  were  a  factor,  one  would  frequently  find  duodenal  ulcer 
associated  with  splanchnoptosis,  which,  according  to  some,  favors  chronic 

*  Boston  Med.  and  Surg.  Jour.,  April  6,  191 1. 
2N.  Y.  Med.  Jour.,  Apr.  18,  1914. 
'Ibid.,  Nov.  25,  1909. 


726  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

mesenteric  traction.  The  writer  has  seen  no  preponderance  of  duodenal 
ulcers  in  such  cases. 

Wm.  J.  Mayo  believes  the  acid  chyme  attacking  the  mucosa  of  the 
duodenum  to  be  an  important  factor,  and  that  when  the  chyme  has  been 
neutralized  by  the  alkaline  juices  of  the  duodenum  it  ceases  to  produce 
irritation.  He  shows  that,  owing  to  anatomic  formation,  the  alkaline 
juices  reach  a  higher  level  in  females  than  in  males,  and  hence,  the  lesser 
number  of  ulcers  of  the  duodenum  in  females.  Recently  he  states  that'^ 
the  same  causes  that  produce  gastric  ulcer,  produce  duodenal  ulcer  and 
further  refers  to  Rosenow'^  theory  of  infection  by  a  specific  streptococcus. 
Mayo  further  believes  a  possible  source  of  injury  may  be  extremely  hot 
and  cold  [drinks  which  pass  rapidly  into  the  duodenum.  R.  T.  Morris^ 
believes  that  toxic  endarteritis,  or  toxic  spasm  of  the  terminal  arteries 
in  the  duodenum,  to  be  an  explanation  of  the  cause  of  duodenal  ulcer  in 
most  cases.  Cobweb  adhesions,  interfering  with  motility  and  leading  to 
acid  hypersecretion  with  local  injury  of  the  mucosa,  he  deems  factors  in 
other  cases,  or  that  colon  bacilli  in  the  terminal  blood-vessels  may  produce 
an  infarct.  Wilkie  believes  that  the  "silent  type"  of  duodenal  ulcer 
occurs  most  frequently  with  cases  suffering  from  arteriosclerosis  and  that 
some  toxic  or  irritative  factor  within  the  abdomen,  often  associated  with 
the  appendix  or  colon,  is  found  with  most  duodenal  ulcers.  The  vascular 
deficiency  may  be  due  to  arteriosclerosis,  but  probably,  usually  to  spasm 
of  the  muscular  coats  of  the  duodenum,  induced  by  local  anemia  conse- 
quent on  a  strain  on  the  supraduodenal  vessels,  the  spasm  being  favored 
by  the  increased  vagotonus  and  the  irritable  condition  of  the  autonomic 
nervous  system.  Lane's  kink  and  simple  vagotonia  have  been  considered 
factors. 

There  is  a  close  association  between  infection  of  the  gall-bladder  or  appen- 
dix or  both,  and  gastric  or  duodenal  ulcers,  the  latter  conditions  probably 
resulting  in  some  cases  from  a  septic  infarct,  or  toxins  from  the  former. 

Frequency. — There  are  wide  discrepancies  in  the  opinions  of  various 
observers  as  to  the  frequency  of  duodenal  ulcer.  The  writer  is  now  refer- 
ring to  the  peptic  type.  Trier  places  it  as  i  to  9  to  the  gastric  as  to  fre- 
quency; while  Andral  gives  i  duodenal  to  40  gastric  ulcers;  and  Starke, 
I  duodenal  to  12  gastric.  Moynihan  believes  duodenal  ulcers  to  be  quite 
common;  and  Wm.  J.  Mayo  has  demonstrated  that  many  pyloric  ulcers 
are  found  to  have  their  origin  in  the  duodenum,  and  in  many  cases  it  is 
impossible  to  differentiate  between  the  two  conditions.  Wm.  J.  Mayo' 
in  1914  placed  the  incidence  of  duodenal  ulcer  as  73  per  cent,  and  gastric 
ulcer  27  per  cent.  Codman  believes  duodenal  ulcer  to  be  more  frequent 
than  gastric  ulcer,  and  to  be  even  as  common  as  acute  appendicitis. 
Deaver'*  holds  that  duodenal  ulcer  outnumbers  gastric  ulcer  in  the  pro- 
portion of  2  to  I ,  and  probably  more.  The  writer  believes  that  undoubtedly 
many  cases  have  been  diagnosed  as  gastric  ulcer,  which  were  duodenal 
ulcers  lying  close  to  the  pyloric  ring.     Ulcer  of  the  duodenum  is  more 

^Journal  A.  M.  A.,  June  19,  1913. 
*  Amer.  Jour,  of  Surg.,  April,  1911. 
8  Ibid. 
*N.  Y.  Med.  Jour.,  March  18,  1911. 


SIMPLE    DUODENAL   ULCER  727 

frequent  than  is  generally  supposed,  but  not  quite  as  frequent  as  gastric 
ulcer,  in  the  author's  opinion. 

In  making  this  statement  the  writer  desires  it  to  be  understood  by 
the  reader  that  his  diagnoses  are  not  made  from  clinical  symptoms  alone 
but  from  confirmatory  evidence  by  the  cjc-rays.  Women  as  a  rule  in  his 
experience,  usually  are  insistent  that  medical  treatment  should  first  be 
attempted  and  will  devote  time  to  the  rest  cure.  Many  cases  will  appar- 
ently result  in  cure  and  then  drift  away  from  the  attending  physician,  so 
that  ultimate  results  are  unknown.  Personally  I  always  advise  operation 
in  chronic  ulcer  cases  whether  of  the  stomach  or  duodenum.  Males  as 
a  rule  prefer  to  secure  a  quick  result  and  do  not  usually  care  to  attempt 
an  ulcer  cure  of  six  weeks  in  bed  with  no  promise  that  operation  may 
not  later  be  required.  I  believe  that  will  explain  in  part  why  the  surgeons 
operate  on  so  many  more  cases  of  duodenal  than  of  gastric  ulcer. 

Moynihan  holds  that  chronic  duodenal  ulcer,  as  far  as  concerns  the 
cases  coming  to  the  surgeon,  is  a  more  frequent  disorder  than  is  ulcer  of 
the  stomach. 

Age. — It  occurs  most  frequently  between  the  ages  of  fifteen  and  sixty. 
It  occurs  in  the  various  decennial  periods  as  follows  in  Moynihan's  ^  cases: 

Years 

I  to  10 None 

10  to  20 3 

20  to  30 37 

30  to  40 56 

40  to  so 45 

50  to  60 27 

60  to  70 II 

Age  not  stated 7 

This  table  refers  to  the  peptic  type  of  duodenal  ulcer.  With  melena 
neonatorum  duodenal  ulcer  is  not  so  uncommon  in  infants. 

The  youngest  was  seventeen  years  of  age  and  the  oldest  sixty-seven. 
These  were  the  ages  given  at  the  time  of  operation  and  not  at  the  com- 
mencement of  the  symptoms.  Many  of  the  patients  who  were  over  forty 
had  had  symptoms  for  some  years.  Case  163,  age  forty-nine,  had  had 
symptoms  for  forty  years,  or  they  dated  from  the  age  of  nine  (see  page 
412,  Moynihan-).  The  operative  findings  in  this  case  appear  to  the 
writer  as  an  ulcerative  process  originating  in  the  gall-bladder  and  not  in  the 
duodenum. 

Some  cases  of  duodenal  ulcer  have  been  reported  by  other  writers  in 
young  children  from  one  to  ten  years  of  age,  and  also  a  number  of  cases  among 
the  newborn.  In  the  latter,  melena  neonatorum  or  thrombosis  of  the 
umbilical  vein,  with  a  deposit  of  the  thrombus  in  a  duodenal  vessel,  with 
a  resulting  infarct,  are  the  factors.  Hereditary  syphilis,  with  local  ulcer 
of  the  duodenum,  has  been  reported.  Kiittner'  reports  death  in  a  child 
four  years  of  age  from  duodenal  ulcers.  The  postmortem  showed  duodenal 
ulcers,  pseudomembranous  colitis,  and  parenchymatous  nephritis.  These 
are  not  the  true  peptic  duodenal  ulcer  and  should  not  be  thus  classified. 

*  Duodenal  Ulcer,  W.  B.  Saunders  Co.,  1912. 

*  Duodenal  Ulcer,  2d  ed.,  W.  B.  Saunders  Co.,  1912. 
'  Berlin,  klin.  Wochensch.,  Nov.  9,  1908. 


728 


DISEASES    OF    THE    STOMACH   AND    INTESTINES 


Gastric  ulcers  occur  in  young  children,  but  less  frequently  than  the 
duodenal  ulcers  described. 

The  average  age  of  death  in  127  fatal  cases  was  thirty-eight  years 
(Rolleston),  but  the  Fen  wicks  show  that  in  the  acute  cases,  68  per  cent, 
proved  fatal  between  fifteen  and  thirty  years;  and  in  chronic  cases  between 
thirty  and  thirty-five  years. 

Sex. — Mayo  reports  61  per  cent,  of  duodenal  ulcers  as  occurring  in 
males.  In  an  analysis  of  186  cases,  Moynihan  reports  its  occurrence  in 
137  males,  or  73.6  per  cent.;  females  49,  or  26.4  per  cent.;  Weir,  30  women 
in  176  cases;  Collins,  52  women  in  257  cases.  The  ratio  is  variously  given 
as  5  men  to  i  woman,  to  3  men  to  i  woman.  The  proportion  of  males 
affected  by  duodenal  ulcer  is  considerably  greater  than  that  of  females. 

Variety  of  Ulcer. — Among  Moynihan's  137  male  patients,  there  were 
107  cases  in  which  duodenal  ulcer  occurred  alone,  and  30  cases  in  which 
there  were  both  gastric  and  duodenal  ulcers.  Of  the  49  female  patients, 
32  had  duodenal  ulcer,  and  17  had  both  duodenal  and  gastric  ulcers. 


Fig.  300. — Duodenal  ulcer  (Le  Tulle).  On  the  right,  the  pyloric  sphincter;  on 
the  left,  the  duodenum,  with  its  mucous  membrane  studded  with  inflammatory  nodules, 
the  glands  of  Briinner,  the  submucosa,  and  the  muscular  coat  uniformly  invaded 
by  the  inflammatory  lesions;  in  the  center,  the  ulcer  cut  out  perpendicularly,  invading 
the  muscular  coat  and  resting  on  the  thickened  peritoneum,  cicatricial  tissue  with  large 
open  vessels  and  lymphatic  glands  chronically  inflamed  (Gaultier). 

Pathology. — William  Mayo  classifies  duodenal  ulcers  surgically  as 
indurated  and  non-indurated.  In  the  former  case  they  have  a  callous 
margin.  The  base  is  formed  usually  of  the  intestinal  muscle,  with  scar 
tissue.  There  may  be  adhesions  to  adjacent  organs,  particularly  to  the 
omentum.  Moynihan  finds  the  majority  free  from  adhesions.  He  be- 
lieves that  the  peptic  duodenal  ulcer  is  usually  chronic.  Others  classify 
duodenal  ulcer  as  acute  and  chronic. 

Melchior^  discusses  chronic  duodenal  ulcers  and  reports  an  acute  case 
of  duodenal  ulcer,  the  hemorrhage  occurring  two  days  after  operation  for 
sarcoma  of  the  thigh.  He  quotes  nine  similar  cases,  and  believes  there  is 
a  diathesis  which  goes  with  a  reduction  in  the  vital  resistance  of  the  wall  of 
the  duodenum  to  the  peptic  action  of  the  gastric  juice.  The  writer,  how- 
ever, thinks  the  occurrence  following  operation  rather  suggestive  of  an 
embolic  ulcer  of  the  duodenum  and  not  of  the  true  peptic  ulcer. 

Characteristics  of  the  Ulcer. — The  duodenal  ulcer  resembles  the  gastric 
ulcer  in  its  clean,  punched-out  appearance.  In  its  earliest  stage  the  ulcer 
^  Berl.  klin.  Wochens.,  Dec.  19,  1910. 


SIMPLE    DUODENAL    ULCER  729 

is  circular;  later  it  may  be  oval  or  oblong.     The  crater  of  the  ulcer  is 
deep  in  proportion  to  its  width  (Fig.  300). 


P'ig.   301. — Duodenal  ulcer.     The  usual  position  and  size  of  the  ulcer  are  well  shown 

(Moynihan). 

In  some  cases  there  seems  to  be  steps  leading  down  the  side  of  the 
ulcer  from  the  lumen  of  the  gut  to  the  base  of  the  ulcer.     This  ridging  or 


Fig.  302. — Duodenal  ulcer.     Showing  adhesions  to  the  gall-bladder.     The  radiating 
scar  is  not  infrequently  seen  (Moynihan). 

"terracing"  is  seen  quite  frequently.     The  walls  of  the  ulcer  are  usually 
thick  and  indurated.     The  outer  surface  (peritoneal)  is  white  and  appears 


730 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


like  a  cicatrix  as  a  rule.  At  times  it  may  be  red,  vascular,  and  mottled 
with  blood-stained  spots.  In  the  older  ulcers  the  base  is  pearly  white  and 
puckered  in  the  center,  which  is  depressed  and  hard.     They  feel  hard  and 


Fig. 


303. — Duodenal  ulcer.     Showing  the  puckering  up  of  the  scar,  which  leads  to 
"pouching"  (drawn  during  operation  upon  the  case)  (Moynihan). 


dense  to  the  fingers,  and  look  smaller  from  the  mucous  than  from  the  serous 
aspect.  In  others  the  entire  breadth  of  the  anterior  wall  of  the  duodenum 
may  be  occupied  by  a  dense,  fibrous  mass,  which  extends  even  to  the  pos- 


Fig.  304. — Chronic  ulceration  of  duodenum  with  formation  of  a  pouch  (Moynihan). 

terior  surface.  It  may  even  have  a  keloid  appearance.  The  ulcer  may 
be  star  shaped,  the  center  being  drawn  in.  In  some,  "  pouching  of  the  gut" 
is  produced,  a  piece  of  the  duodenal  wall  being  almost  separated  from  the 
rest,  so  that  a  diverticulum  is  formed. 


SIMPLE    DUODENAL    ULCER 


731 


In  the  majority  a  healthy  margin  of  the  bowel  lies  between  the  ulcer 
and  the  pylorus,  but  the  lesion  may  extend  to,  within,  or  through  the 
pylorus. 

Mayo  has  shown  that  the  gastric  margin  of  the  ulcer  may  be  the  start- 
ing-point of  a  carcinomatous  growth.  The  occurrence  of  a  malignant 
change  in  a  simple  duodenal  ulcer  is  extremely  rare,  while  it  is  quite  fre- 
quent in  gastric  ulcer.  In  Fig.  301  is  shown  the  usual  position  and  size 
of  a  duodenal  ulcer.  In  Fig.  302  we  have  an  ulcer  with  adhesions,  and 
in  Figs.  303  and  304  a  "pouching  ulcer." 

Site  of  the  Ulcer. — In  at  least  95  per  cent,  of  all  cases  the  ulcer  lies 
within  the  first  portion  of  the  duodenum;  that  is,  within  i^  inches  of  the 
pylorus.  In  Collins'  cases,  262  in  all,  the  ulcer  was  found  in  the  first 
portion  of  the  duodenum  in  242  cases;  in  the  second  part,  in  14;  in  the 


Fig. 


—  1' 


\eiii   which   siiows   Luc  puMLiuii   oi 
CMoynihanj. 


lie  pylorus  ("pyloric    vein") 


third,  in  3;  and  in  the  fourth,  in  3.  In  the  cases  in  which  the  ulcer  is 
"tucked  back,"  adherent  to  the  liver  or  posterior  wall  of  the  abdomen, 
in  which  event  the  pain  comes  on  three  or  four  hours  after  food  instead 
of  two  hours,  though  the  ulcer  may  apparently  be  situated  in  the  second 
part  of  the  duodenum,  if  the  position  of  the  pyloric  vein  be  noted,  it  will 
be  seen  that  the  ulcer  is  within  J.^  to  ^4  inch  from  the  pylorus.  This  vein 
(Fig.  305)  is  an  important  landmark,  and  generally  runs  a  little  to  the 
gastric  side  of  the  pylorus,  and  its  recognition  enables  the  operator  to  at 
once  determine  where  the  stomach  ends  and  the  duodenum  begins.  The 
vein  runs  upward  from  the  greater  curvature,  is  thick  and  short,  and  may 
often  be  met  by  a  smaller  vein  descending  from  the  lesser  curvature. 
Usually  there  is  no  visible  anastomosis.  The  ulcer  is  generally  situated  on 
the  anterior  wall  of  the  duodenum,  midway  between  the  upper  and  lower 
border,  about  ^  inch  beyond  the  pylorus.     This  part  of  the  duodenum 


732 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


is  apparently  prone  to  attack,  possibly  because  the  chyme  directly  im- 
pinges there  as  it  is  expelled  through  the  pylorus.  Occasionally  the  ulcer 
is  found  on  the  upper  or  lower  border  and  rarely  on  the  posterior  surface. 
One  case  of  circular  ulcer  dividing  the  duodenum  and  opening  into  a  local 
abscess  is  recorded  by  Meunier/  Fig.  306. 

Recurrences. — The  recurrence  of  attacks  in  duodenal  ulcer  may  be  due 
to  the  healing  and  breaking  down  of  a  single  ulcer  or  to  the  development 
of  new  ulcers.  The  former  is  more  frequent,  as  in  only  10  to  20  per  cent, 
of  cases  is  more  than  one  ulcer  found.  Occasionally  a  large  ulcer  may  be 
due  to  the  merging  of  one  small  ulcer  into  another  and  so  on.  A  large 
mass  of  fibrous  tissue  may  occasionally  be  found.  There  is  usually  one 
ulcer,  from  the  size  of  a  lentil  to  a  dollar. 


Fig.  306. 


-Circular  ulcer  of  duodenum.     Perforation  into  a  localized  abscess  (Moynihan, 
after  Meunier). 


Number  of  Ulcers. — In  about  10  to  20  per  cent,  of  cases,  as  noted 
above,  the  ulcers  are  multiple.  Occasionally,  from  two  to  four  or  more 
ulcer  scars  are  seen  on  the  anterior  surface  of  the  duodenum,  together 
with  a  new  active  ulcer.  Old  ulcers  and  new  ones  are  found  side  by  side; 
and  when  two  ulcers  are  present,  they  are  generally  almost  touching. 
One  may  he  on  the  posterior  wall,  opposite  the  anterior  ulcer.  When  the 
gut  is  empty,  they  seem  to  be  in  apposition;  and  Moynihan  suggests  the 
term  of  "kissing"  or  contact  ulcers  (Fig.  307).  When  several  ulcers  are 
present  they  are  usually  found  in  the  first  part  of  the  duodenum.  As 
many  as  nine  ulcer  scars  have  been  seen  within  the  space  of  i}^i  inches. 

Complications. — Stenosis  of  the  duodenum  near  the  pylorus,  or  even 
at  a  greater  distance,  may  occur,  with  resulting  dilatation  of  the  stomach 
1  Bull.  Soc.  Anat.,  1893,  i,  488. 


SIMPLE   DUODENAL   ULCER 


733 


and  the  symptoms  of  benign  stricture,  the  same  as  in  the  stenosis  of  gastric 
ulcer.     The  stricture  of  the  duodenum  may  be  thin  and  narrow,  the  bowel 


Fig.  307. — A,  Perforating  ulcer  on  anterior  surface  of  duodenum;  B,  "kissing 
ulcer"  on  posterior  surface;  C,  pyloric  ring;  D,  cut  edge  of  lesser  curvature  of  stomach. 
Note  the  position  of  the  ulcers  immediately  outside  the  pylorus. 

The  specimen  was  removed  from  a  woman  aged  thirty,  who  died  about  two  hours 
after  admission  to  the  Royal  Victoria  Hospital,  Belfast,  May,  1909.  No  operation  was 
undertaken.  From  a  photograph  kindly  given  to  Mr.  B.  G.  A.  Moynihan  bv  Dr.  A. 
B.  Mitchell,  Belfast  (Moynihan). 

appearing  as  if  a  string  had  been  tied  about  it  ("hour-glass"),  or  the 
stricture  may  be  long,  tortuous,  and  markedly  indurated.  In  Figs.  308 
and  309  we  have  illustrated  the  hour-glass  condition. 


308. — Hour-glass    stomach    and    riuodenum    (.Moj'nihan;. 


Jaundice,  with  marked  inanition  and  distention  of  the  gall-bladder  and 
inflammatory  conditions  therein,  may  result  from  stenosis  from  ulcers 
which  blocks  the  common  bile-duct,  so  that  pancreatic  carcinoma  is  sus- 


734 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


pected.  Atrophy  of  the  pancreas  or  chronic  pancreatitis  may  take  place 
from  closure  of  the  pancreatic  duct.  The  type  of  hemorrhage  is  usually 
severe  with  the  pancreatitis.  Fatal  hemorrhage  may  occasionally  occur. 
In  acute  cases  quite  frequently  perforation  and  general  peritonitis 
result,  with  death  from  shock  or  peritonitis.  If  the  process  is  slower, 
there  may  be  a  circumscribed  peritonitis  with  abscess.  There  may  be 
adhesions  to  the  omentum  and  with  other  organs  and  ulcerations  involving 
the  liver,  gall-bladder,  pancreas,  aorta,  portal  vein,  or  hepatic  artery. 
Subphrenic  abscess  may  result.  Thrombosis  of  the  portal  vein  has  also 
resulted  from  the  deep  cicatrization  of  an  ulcer.  The  blood-vessels  of  the 
duodenum  have  frequently  been  eroded,  chiefly  the  gastroduodenal,  the 
pancreaticoduodenal,  and  the  right  gastro-epiploic  arteries.  In  one  case 
the  hepatic  artery  was  eroded,  and  in  a  few  cases  there  was  an  aneurysmal 
dilatation  of  the  vessel  at  the  point  of  rupture.  Perforations  of  the  aorta, 
portal  vein,  and  superior  mesenteric  vein  have  been  reported.  Hepatic 
abscess  may  result  from  duodenal  ulcer.  Two  cases  of  duodenocolic 
fistulae  are  recorded. 


Fig.  309. — Double  stenosis  in  the  duodenum  ("hour-glass  duodenum")    (Moynihan, 

after  W.  J.  Mayo). 

Ulcus  Carcinomatosum. — Change  from  a  simple  ulcer  of  the  duodenum 
to  a  malignant  condition  is  extremely  rare.  W.  J.  Mayo^  reports  four 
cases.  Perry  and  Shaw  report  five  cases;  Boxwell,^  one  case;  Ewald,^ 
one  case;  Eichhorst,^  one  case;  and  Arnold  and  S.  Fenwick,  each  one  case. 

Cancer  developing  on  the  edge  of  a  duodenal  ulcer  which  has  involved 
the  stomach  at  the  pyloric  ring  is  more  frequent. 

Clinical  Aspects. — Occasionally  the  cicatrix  of  an  old  ulcer  may  be 
found  at  autopsy,  though  there  have  been  no  symptoms  during  life. 
Other  patients  may  be  apparently  in  perfect  health,  when  suddenly  a 
severe  and  dangerous  intestinal  hemorrhage  takes  place,  or  perforation  of 
the  intestine  and  resulting  peritonitis.  As  in  many  cases  the  ulcer  is  free 
from  adhesions,  there  is  great  danger  when  perforation  occurs.  In  some 
the  omentum  fortunately  adheres. 

*  Jour.  Amer.  Med.  Assoc,  1908,  ii,  558. 
^Lancet,  1907,  ii,  1687. 

'  Berl.  klin.  Wochens.,  1886,  No.  32,  p.  527. 

*  Zeitschr.  f.  klin.  Med.,  1888,  xiv,  519. 


SIMPLE    DUODENAL    ULCER 


735 


Symptoms. — In  discussing  the  symptoms  of  duodenal  ulcer,  the  author 
must  take  exception  to  the  statement  of  Moynihan  that  either  hyperchlor- 
hydria,or  acid  gastritis  "is"  duodenal  ulcer.  Acid  gastritis  is  a  definite 
clinical  entity;  while  hyperchlorhydria,  in  many  cases,  is  a  functional  dis- 
turbance and  readily  cured.  The  writer  does  believe,  however,  that  a 
"persistent  hyperchlorhydria,"  or  persistent  symptoms  simulating  such, 
are  suggestive  of  either  gastric, or  duodenal  ulcer.  The  determination  of 
pus  in  the  gastric  contents  alone,  or  with  the  presence  of  blood  or  occult 
blood,  point  to  the  stomach;  while  the  absence  of  pus  in  the  gastric  con- 
tents, and  the  presence  of  blood  or  occult  blood  in  the  stool  and  sometimes 
in  the  stomach  in  addition,  point  to  the  duodenum.^  In  some  cases  both 
stomach  and  duodenum  may  be  involved. 

Acute  Duodenal  Ulcer. — The  writer  has  seen  a  few  cases  of  acute  duo- 
denal ulcer  of  apparently  brief  duration,  '  They  occurred  in  males.     There 


Fig.  310. — Profile  of  ulcer:     A,  cap;  B,  everted  edge  of  ulcer;  C,  crater  of  ulcer;  D, 
everted  edge  of  ulcer;  E,  fleck  of  bismuth  in  crater  of  ulcer  (Lewis  Gregory  Cole*). 

were  pain  and  tenderness  in  the  epigastrium  to  the  right  of  the  linea  alba, 
over  the  duodenum;  vomiting  was  rare,  melena  and  collapse  were  marked, 
and  subsequent  gastric  analysis  showed  marked  hyperchlorhydria;  no  pus, 
no  occult  blood.  Severe  secondary  anemia  was  present  after  the  hemorrhage. 
Recurrent  hemorrhage  may  also  occur  in  the  gastric  contents.  As  a  rule, 
duodenal  ulcer  is  characterized  by  its  chronicity. 

Chronic  Ulcer. — The  writer  believes  the  anamnesis  to  be  of  exceptional 
importance,  but  that  repeated  and  persistent  tests  for  occult  blood  in  the 
stool  in  suspected  cases,  even  in  the  early  stage,  to  be  of  diagnostic  value, 
and  also  the  use  of  the  microscope,  in  that  the  latter  will  show  the  presence 
or  absence  of  pus,  and  aid  in  differential  diagnosis  between  gastric  and 
duodenal  ulcer.  There  are,  however,  certain  symptoms  which  are  char- 
acteristic of  duodenal  ulcer.  Thus:  A  long  history  {chronicity);  the 
periodicity  of  the  symptoms,  and  their  recurrence  from  time  to  time  in 


^  Radiography  settles  the  diagnosis. 

*  The  diagnosis  of  post-pyloric  (duodenal)  ulcer. 


The  Lancet,  May  2,  1914. 


736  DISEASES   OF    THE    STOMACH   AND   INTESTINES 

"attacks;"  and  their  complete  abeyance  in  the  intervals.  The  fact  that 
persistent  treatment  fails  to  cure  the  patient  is  most  suggestive.  Occa- 
sionally even  after  persistent  stool  examination,  occult  blood  may  not 
be  found.     The  Aivrays,  however,  will  determine  the  presence  of  the  ulcer. 

X-rays. — In  every  event  when  possible,  examination  should  be  made 
with  the  x-rays  which  will  demonstrate  as  a  rule  some  deformity  in  the 
cap  (ascending  duodenum)  or  retention  in  the  duodenum  (see  Fig.  310), 
or  as  Codman  shows  in  cases  without  scar  tissue,  a  hyperperistalsis  of  the 
stomach  with  subsequent  bismuth  retention  in  some  cases.  A  full  descrip- 
tion of  the  radiological  findings  is  given  in  the  section  on  "jc-rays  in  gastro- 
intestinal disease." 

Spasm  of  the  duodenum  may  occur  as  a  reflex  from  a  chronic  appen- 
dicitis, or  gall-bladder  inflammation,  and  from  other  causes.  This  condi- 
tion has  been  described  by  Carman.  I  always  advise  examination  at 
time  of  operation  of  the  appendix  and  gall-bladder  as  well  as  of  the  duo- 
denum. The  method  of  prevention  of  duodenal  spasm  is  described  in 
the  section  on  a:- rays  (duodenal  ulcer). 

History  of  Sjmiptoms. — The  patient,  moreover,  frequently  dates  his 
complaint  from  an  early  period,  with  intermitting  periods  of  comfort.  As 
a  rule,  he  is  from  twenty-five  to  forty-five  years  of  age;  males  are  more 
frequently  affected. 

The  early  symptoms  are  a  sense  of  weight,  oppression,  or  distention  in 
the  epigastrium  after  meals.  The  discomfort  appears  usually  two  hours 
or  a  little  more  after  food  has  been  taken.  There  is  comfort  immediately 
after  a  meal;  if  pain  or  discomfort  were  present  before,  the  meal  relieves 
them  for  a  time.  Then,  again,  the  pain  is  felt  in  two,  three,  four,  or  even 
six  hours  later.  When  it  occurs  three  or  four  hours  after  food,  Moynihan 
finds  that  the  ulcer  is  "  tucked  back."  And  when  the  pain  comes  on  earlier 
than  two  hours  after  food,  either  there  are  recent  adhesions  between  the 
ulcer  and  the  liver  or  abdominal  wall,  or  pyloric  stenosis  is  beginning  to 
develop. 

Pain. — Usually  the  pain  comes  on  gradually  and  increases  gradually 
in  severity,  being  accompanied  by  a  sense  of  fulness  and  distention  ("a 
blown-up  feeling").  There  is  later  an  eructation  of  fluid  or  gas,  which 
affords  relief.  The  interval  between  the  taking  of  food  and  the  onset  of  the 
pain  is  constant  from  day  to  day,  providing  the  quantity  and  character 
of  the  food  remain  the  same.  With  liquid  food  the  pain  comes  earlier, 
as  a  rule;  while  with  food  that  is  solid  and  indigestible,  the  pain  comes 
later;  while  with  an  ordinary  meal  (liquid  and  solid),  the  pain  rarely 
appears  in  less  than  two  hours.  The  author  finds,  however,  that  this  is 
not  invariably  the  case,  as  in  a  recent  case  examined,  of  seventeen  years' 
duration,  no  solid  food  could  be  taken  at  all,  liquids  alone  being  ingested 
with  comfort.  Discomfort  and  pain  appeared  at  the  end  of  three  hours, 
and  this  was  temporarily  reUeved  by  milk  feeding.  ''Hunger  pain"  has 
been  suggested  as  descriptive  of  this  symptom,  since  patients  state  that 
it  appears  when  they  are  beginning  to  feel  hungry.  There  have  been 
several  explanations  offered  as  to  the  cause  of  hunger  pain,  and  it  would 
seem  difficult  to  determine  why  bland  liquid  often  causes  an  earlier  ap- 
^Jour.  Amer.  Med.  Assoc,  April  22,  1916. 


SIMPLE    DUODENAL    ULCER  737 

pearance  of  pain.  It  has  been  clearly  demonstrated  by  the  x-rays  that 
liquids  pass  out  along  the  lesser  curvature  early  and  with  great  rapidity. 
The  writer  believes  the  earlier  appearance  of  pain  to  be  due  to  the  earlier 
and  more  active  pyloric  contraction,  with  resulting  movements  of  the 
irritable  ulcer.  Cannon  has  shown  that  the  waves  (motor)  in  the  fundus 
are  slight,  and,  unquestionably,  for  at  least  an  hour  a  considerable  por- 
tion of  the  solid  food  lies  in  this  region,  while  it  is  further  acted  on  by  the 
ptyalin.  The  smaller  quantities  of  soUd  food  which  pass  frpm  the  stomach 
at  this  period  are  well  diluted  with  liquid.  Later,  the  undiluted  chyme 
passes  out  in  larger  quantity,  with  increased  pyloric  movements,  and  also 
increased  motility  in  the  ulcerated  region.  Moynihan  holds  that  probably 
the  acid  content  is  greater  at  that  period,  or  possibly  some  other  change 
has  taken  place  in  the  chyme,  which  increases  the  irritating  efifects. 
Codman  also  calls  attention  to  the  primary  symptoms  of  "hunger  pain" 
and  indigestion.  The  pain  is,  as  a  rule,  noticed  at  first  only  after  the 
heaviest  meal  of  the  day.  For  example,  if  dinner  is  taken  between  i  and 
2  p.  M.,  the  pain  will  appear  regularly  about  4  p.  m.  Frequently  this  is 
the  only  time  when  discomfort  is  felt;  but  later,  or  in  subsequent  attacks, 
the  pain  comes  on  at  the  usual  interval  after  every  meal;  though  tem- 
porarily, after  the  meal  the  pain  is  relieved,  but  only  to  return  in  time. 
The  patient  usually  states  that  "food  makes  the  pain  better,  and  that  the 
pain  comes  on  when  he  begins  to  feel  hungry."  It  is  quite  characteristic 
that  the  pain  should  awake  the  patient  in  the  night,  generally  about  2  a.  m. 
The  patient  soon  realizes  that  food  relieves  the  pain,  and  so  has  at  hand 
a  biscuit,  or  bread  and  butter,  or  milk,  to  be  taken  when  it  begins;  and 
food  is  often  kept  beside  the  bed,  to  be  taken  early  in  the  morning  when 
awakened  by  the  pain.  Stockton^  has  demonstrated  experimentally 
that  the  mechanical  stimulus  given  by  the  food  to  the  stomach  excites  a 
reflex  flow  of  the  alkaline  duodenal  secretion,  which  neutralizes  the 
irritating  hydrochloric  acid  present  in  the  duodenum  and  J.  T.  Pilcher^ 
makes  the  same  claim.  The  appearance  of  the  pain  at  definite  intervals 
after  taking  food  is  consistent.  A  sensation  of  weight,  or  fulness,  or  dis- 
tention, in  the  epigastrium,  often  precedes  or  accompanies  the  pain.  It 
may  be  of  a  boring,  gnawing,  or  burning  character,  and  it  may  be  relieved 
by  belching.  The  patient  often  endeavors  to  eructate  gas  in  order  to 
secure  temporary  relief.  Slight  regurgitation  of  food  sometimes  occurs. 
This  may  taste  bitter  or  acid,  and  the  throat  may  feel  scalded,  and  the 
teeth  like  chalk.  The  salivary  flow  may  be  copious  and  cause  consider- 
able annoyance.  In  some,  swallowing  the  saliva  may  temporarily  re- 
lieve the  discomfort.  The  author  has  seen  some  cases  in  which  the  pain 
was  not  marked,  but  there  was  more  a  sensation  of  dull  ache  or  local 
discomfort. 

For  a  long  period,  sometimes  throughout  the  entire  history,  the  pain 
may  remain  confined  to  the  epigastrium.  It  may  pass  through  to  the 
back,  or  around  the  right  side,  and  may  radiate  down  into  the  abdominal 
cavity.  In  my  own  experience  I  have  not  seen  it  pass  into  the  back,  as 
in  gastric  ulcer,  but  it  lies  rather  to  the  right  of  the  linea  alba.     Pressure 

'  N.  Y.  State  Journal  of  Medicine,  Oct.,  1913. 
-  Med.  Rec,  July  26,  ^913. 

47 


738  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

at  times  gives  relief,  such  as  by  hugging  a  pillow  to  the  abdomen.     In 
some  cases  the  pain  is  cramp-like,  a  spasm  is  felt  with  exacerbations  and 
remissions,  as  in  colic.     This  is  probably  due  to  spasm  of  the  pylorus.  - 
Great  epigastric  distention  occurs  with  it,  with  a  feeling  almost  of  bursting. 
The  appetite  remains  good  during  the  period  of  pain. 

The  patient  may  eat  less  than  he  desires  to,  since  he  has  learned  by 
experience  that  excess  or  even  satiation  of  the  appetite  may  be  followed 
by  a  more  enduring  pain. 

Fluid  food,  as  previously  noted,  when  taken  alone,  may  cause  the  pain 
to  come  earlier  and  to  last  longer  than  after  ordinary  meals.  For  a  while 
the  patient  may  feel  worse  on  the  liquid  diet;  but  persistence  in  the  latter 
will  bring  relief  after  a  time. 

Vomiting  is  infrequent  and  is  rarely  present  until  stenosis  develops. 

Stenosis  appears  in  the  late  period  when  the  ulcer  is  healed  or  nearly 
so,  or  pyloric  spasm  may  produce  an  evanescent  stenosis. 

The  symptoms  of  duodenal  ulcer  are  periodic,  they  recur  from  time 
to  time  in  ^^ attacks"  and  they  are  in  abeyance  in  the  intervals.  The  "at- 
tack" may  come  on  as  a  result  of  exposure  to  cold,  wetting  the  feet,  a 
hasty  or  indigestible  meal,  or  worry  or  overwork. 

*' Catching  cold"  is  a  frequent  cause,  the  attacks  being  most  prevalent 
in  December,  January,  or  February. 

The  symptoms  are  nearly  always  absent  in  summer. 

The  attack  may  follow  another  disease,  such  as  influenza.  The  at- 
tacks may  vary  in  length  from  two  to  three  weeks  to  several  months,  and 
a  few  days  rest  in  the  country  or  at  the  seashore  may  cut  them  short. 

The  onset  and  termination  may  be  sudden.  A  chill  may  bring  on 
the  attack  immediately  and  the  symptoms  may  continue  for  months. 
At  times  they  may  cease  abruptly.  On  the  other  hand,  the  pain  may 
become  a  daily  occurrence  and  retain  its  peculiar  character. 

In  the  intervals  between  attacks  there  is  complete  immunity  from 
pain,  and  food  is  taken  with  enjoyment,  there  is  no  discomfort,  and  there 
is  a  gain  in  weight.  The  recovery  may  apparently  be  complete.  The 
patient  or  physician  may  believe  the  case  to  be  one  of  acid  dyspepsia  or  a 
neurosis. 

All  these  symptoms  may  be  present  for  years  without  any  physical  signs. 

Though  the  anamnesis  is  extremely  important,  the  writer  does  not 
agree  with  Moynihan's  statement,  that  it  is  not  necessary  for  an  accurate 
diagnosis  that  any  exmination  of  the  patient  should  be  made.  Repeated 
and  frequent  examinations  of  the  stool  should  be  made  for  occult  blood. 
The  writer  believes  it  can  usually  be  discovered.  Bleeding  from  hemor- 
rhoids should,  of  course,  be  excluded.     The  test-meal  is  also  important. 

In  many  cases,  especially  in  the  stage  when  the  ulcer  is  latent,  or  be- 
tween the  presence  of  symptoms,  nothing  may  be  revealed  by  physical 
examination.  There  may  be  some  epigastric  tenderness  in  the  middle 
line  or  to  the  right.  During  the  period  of  pain,  between  two  or  tliree 
hours  after  a  meal,  there  is  usually  some  tenderness,  which  may  rarely 
be  marked.  This  may  be  in  the  middle  line  over  an  area  of  2  or  3  inches. 
The  pyloric  region  may  in  some  be  sensitive.  Tenderness  on  pressure 
over  a  small  circumscribed  point  is  more  frequent  with  gastric  ulcer. 


SIMPLE   DUODENAL   ULCER  739 

In  some  cases,  however,  of  duodenal  ulcer,  there  may  be  continuous 
pain  and  tenderness  due  to  a  local  peritonitis.  Rarely  pain  and  tender- 
ness appear  on  the  left  side  for  which  there  is  no  explanation.  When 
acute  pain  is  present  the  right  epigastric  reflex  may  be  strongly  accentu- 
ated. Local  tenderness  is  usually  combined  with  local  rigidity,  and  the 
upper  part  of  the  right  rectus  muscle  may  be  contracted  and  tense. 

Hence,  tenderness  in  the  middle  line  and  to  the  right,  accentuation 
of  the  right  epigastric  reflex,  and  rigidity  of  the  right  upper  rectus  are 
the  chief  physical  signs  of  duodenal  ulcer;  they  may  be  absent. 

Vomiting  is  rare  with  duodenal  ulcer,  unless  there  is  stenosis  with 
dilatation  of  the  stomach,  and  this  condition  occurs  in  the  later  stages. 
With  reflex  spasm  of  the  pylorus,  vomiting  occasionally  occurs,  but  it 
does  not  relieve  the  pain  of  duodenal  ulcer  as  it  does  that  of  gastric  ulcer. 
A  regurgitation  of  acid  chyme  is,  however,  quite  frequently  present. 

When  stenosis  occurs,  we  have  the  physical  signs  of  dilatation  of  the 
stomach,  with  peristaltic  unrest,  vomiting,  motor  insufficiency,  etc. 

S.  Kemp^  believes  that  hypersecretion  suggests  either  gastric  or 
duodenal  ulcer  as  a  rule,  and  when  it  is  excessive,  it  speaks  strongly 
for  duodenal  ulcer;  in  fact,  he  believes  it  more  frequent  with  the  last. 
Pyloric  spasm  was  quite  frequent  with  duodenal  ulcer,  and  gastric  motor 
insufficiency  he  believed  to  be  the  rule.  The  author  only  finds  hyper- 
secretion, and  motor  insufficiency  in  the  advanced  cases  with  stenosis. 

Examination  of  the  Blood. — Secondary  anemia,  often  quite  severe  is 
found,  after  hemorrhage  in  acute  cases  of  duodenal  ulcer;  and  I  have  ob- 
served secondary  anemia  quite  marked  in  chronic  cases  where  there  was 
evidence  in  the  stool  of  repeated  small  hemorrhages.  Friedman^  reports 
polycythemia  in  cases  of  duodenal  ulcer  of  non-hemorrhagic  type,  and 
holds  that  it  is  an  important  aid  to  the  diagnosis,  and  claims  the  following 
differences  in  the  blood  picture  of  gastric  ulcer  and  non-hemorrhagic 
duodenal  ulcer. 

Gastric  ulcer  Duodenal  ulcer 

Anemia  Polycythemia  (erythrocytosis) 

Eosinophilia  Eosinopenia 

Bowels. — Constipation  is  the  rule,  diarrhea  rarely  occurs. 

Gastric  Contents. — The  test-breakfast  should  be  given  in  all  cases.  The 
patients  usually  complain  of  an  acid  stomach  (hyperacidity).  In  the 
writer's  own  experience,  in  the  cases  with  acute  symptoms,  with  melena 
or  a  clear  history  of  hemorrhage,  he  has  found  hyperchlorhydria  present. 
This  corresponds  with  Boas'  observations.  On  the  other  hand,  the  in- 
tractible  cases  of  so-called  "acid  dyspepsia"  of  long  standing  which  do 
not  yield  to  remedies,  and  which  are  recurrent,  Moynihan  believes  to  be 
due  to  duodenal  ulcer.  In  the  type  of  chronic  duodenal  ulcer,  the  gastric 
juice  often  contains  less  free  HCl  than  normal,  in  spite  of  the  symptoms 
of  hyperchlorhydria.  The  Mayos  report  a  number  of  cases  of  chronic 
duodenal  ulcer  with  hyperacidity  or  on  the  border  line  between  normal 
acidity  and  hyperacidity.     On  the  other  hand,  the  cases  which  have 

'  Ungekrift  for  Laeyer,  Copenhagen,  Dec.  15,  1910,  Ixxii,  Nos.  49  and  50. 
2  Med.  Rec,  May  16,  1914,  and  same  Oct.  18,  1913. 


740  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

progressed  to  stenosis  of  the  pylorus,  and  dilatation  of  the  stomach 
have  hyperacidity  as  a  rule;  but  in  these  the  chief  symptoms  are  re- 
ferable t6  the  mechanical  obstruction.  Even  the  absence  of  free  HCl 
and  the  presence  of  lactic  acid  have  been  reported  in  cases  of  duodenal 
ulceration. 

As  about  50  per  cent,  of  one's  private  office  cases  suffer  from  true 
hyperchlorhydria  (an  excess  of  free  HCl  above  normal,  in  addition  to 
excessive  total  acidity),  the  writer  absolutely  disagrees  with  Moynihan 
in  his  statement  that  the  term  hyperchlorhydria  is  a  misnomer,  is  due  to 
an  organic  condition,  and  is  never  functional,  and  that  the  presence  of 
an  excess  of  acid  is  most  infrequent.  Hyperchlorhydria  results  chiefly 
from  dietary  indiscretions,  and  also  is  associated  with  chlorosis,  gastrop- 
tosis,  and  nervous  conditions.  There  may  be  attacks  with  free  intervals, 
just  as  in  the  case  of  duodenal  ulcer;  excepting  in  the  pure  nervous  cases, 
or  those  reflex  from  the  gall-bladder  and  appendix,  the  character  of  the 
food  may  influence  the  attacks. 

Simple  hyperchlorhydria  is,  as  a  rule,  amenable  to  treatment.  Hyper- 
chlorhydria with  gastric  ulcer  is  present  in  the  acute  cases — in  the  author's 
opinion,  with  a  history  of  hematemesis  and  melena.  In  hyperacidity 
cases  not  amenable  to  treatment  gastric  ulcer  is  often  also  present. 
Hyperchlorhydria  occurs  in  acute  cases,  of  duodenal  ulcer  with  melena. 

Symptomatic  hyperacidity — recurrent  and  intractable  with  less  HCl  than 
normal  is  suggestive  of  chronic  duodenal  ulcer. 

The  presence  of  blood  visible  or  occult,  and  pus  in  the  gastric  con- 
tents, are  diagnostic  of  gastric  ulcer.  Of  course,  pus  from  the  pharynx 
or  from  gastric  abscess  must  be  excluded.  Preliminary  antiseptic  naso- 
pharyngeal sprays,  a  preliminary  lavage,  and  sterile  diet  are  valuable 
methods  to  exclude  ingested  pus. 

The  determination  of  pus,  therefore,  diagnoses  ulcer  affecting  the 
stomach  either  benign  or  malignant  in  type,  or  achlorhydria  haemor- 
rhagica  gastrica.  In  the  latter  condition  other  peculiarities  of  the  gastric 
contents  are  present  which  are  described  under  that  subject.  With 
achlorhydria  hemorrhagica  free  HCl  notably  is  absent,  and  microorganisms 
are  in  excess. 

On  the  other  hand,  melena  is  most  frequent  with  duodenal  ulcer  and 
hematemesis  is  less  frequent.. 

If  the  examination  of  .the  gastric  contents  show  an  absence  of  pus, 
occult  blood  present  or  more  usually  absent,  and  occult  blood^  be  found 
present  in  the  stool,  the  case  is  one  of  duodenal  ulcer. 

Acid  gastritis  is  hyperchlorhydria  with  mucus,  an  early  stage  of  chronic 
gastritis  and  an  entity  in  itself. 

These  .features  show  the  importance  of  the  test-meal.  Gross  has 
recently  suggested  aspirating  the  duodenal  contents  with  his  duodenal 
pump  and  examining  for  blood  and  occult  blood.  The  method  may 
possibly  prove  of  service. 

Hemorrhage. — This  sign  sometimes  appears  early,  but  is  more  fre- 
quently a  late  symptom.  Visible  hemorrhage  Moynihan  believes  a  sign 
of  neglected  opportunity.  Various  authors  place  the  frequency  of  hemor- 
1  Hemorrhoids   and  other  causes   must  be  excluded. 


SIMPLE   DUODENAL   ULCER  74 1 

rhage  as  occurring  in  about  one-third  of  all  cases,  while  Moynihan  notes 
it  in  37.6  per  cent. 

When  hemorrhage  occurs,  it  may  manifest  itself  either,  more  rarely  as 
hematemesis,  vomiting  of  blood,  or  usually  as  melena  (blood  in  the  feces) ; 
as  a  rule,  the  blood  has  a  tar-like  or  coffee-ground  appearance.  Sometimes 
both  occur,  but  melena  is  the  most  frequent,  without  hematemesis. 

Hemorrhage  from  duodenal  ulcer  is  far  more  serious  than  bleeding 
from  a  gastric  ulcer.  There  may  be  first  an  exacerbation  of  the  indiges- 
tion and  a  feeling  of  distention.  The  patient  may  suddenly  become 
faint  and  weak,  the  head  feels  light,  and  he  becomes  pale,  the  forehead 
covered  with  sweat,  and  he  asks  for  air.  There  are  all  the  signs  of  an 
internal  hemorrhage.  Tarry  blood  may  be  voided  in  the  stool  or  brighter 
blood  vomited.  The  patient  may  bleed  to  death  without  any  visible 
blood.  Death  from  hemorrhage  may  be  nearly  instantaneous,  when 
.  such  vessels  as  the  aorta,  the  hepatic,  superior  pancreaticoduodenal  right 
gastro-epiploic  and  pyloric  arteries,  or  the  portal  or  superior  mesenteric 
veins  are  eroded. 

On  the  other  hand,  there  may  be  progressive  anemia  and  weak- 
ness with  no  particular  symptoms,  resulting  from  smaller  repeated 
hemorrhages. 

Undoubtedly  careful  and  repeated  examination  of  the  stools  and  gastric 
contents  for  occult  blood  by  Weber's,  the  benzidin,  or  phenolphthalein 
tests,  would  demonstrate  that  ulcer  is  present  in  every  suspected  case. 
A  number  of  examinations  may  be  necessary,  but  the  writer  believes 
occult  blood  can  ultimately  usually  be  found  in  the  stool.  A  meat-free  diet 
for  two  days,  administration  of  a  coarse  diet,  and  eHmination  of  bleed- 
ing from  hemorrhoids,  are  necessary  precautions.  Celery,  radishes, 
etc.  (coarse  ballast),  fret  the  ulcerated  surface  and  tend  to  cause  slight 
hemorrhage. 

Einhorn  suggests  the  thread  impregnation  test,  as  described  under  the 
gastric  ulcer.  The  writer  believes,  however,  that  if  blood  is  present  in 
sufficient  quantity  to  discolor  the  thread,  the  occult  blood  test  will 
invariably  be  present.     The  thread  test  is  uncertain. 

Moynihan's  statistics  are  as  follows:  70  patients  (37.6  per  cent.) 
gave  a  history  of  bleeding.  Of  these  7  had  hematemesis  alone,  23  had 
melena  alone,  30  had  both  hematemesis  and  melena. 

Out  of  139  cases  in  which  duodenal  ulcer  alone  was  found,  hemor- 
rhage was  noted  in  49  cases  (35.2  per  cent.);  9  had  hematemsis  alone  (6.4 
per  cent.);  18  had  melena  alone  (13  per  cent.);  22  had  hematemesis  and 
melena  (15.8  per  cent.).  In  18  cases  the  hemorrhage  was  severe — in  all 
9.2  per  cent,  suffered  from  dangerous  bleeding. 

Jaundice. — ^Jaundice  is  rare  with  duodenal  ulcer.  The  development 
of  icterus  in  a  case  presenting  some  of  the  symptoms  of  gastric  ulcer, 
probably  shows  duodenal  ulcer,  if  gall-stones  can  be  excluded. 

The  death-rate  from  hemorrhage  is  quite  large  and  is  variously 
estimated  at  from  13  to  ;^^  per  cent. 

Tetany. — Three  cases  gave  a  history  of  tetany. 

Cardiospasm. — In  three  cases  cardiospasm  was  present. 

Dilatation  of  the  Stomach. — In  a  small  number  of  cases  the  symptoms 


742 


DISEASES   OF   THE    STOMACH    AND    INTESTINES 


of  active  ulceration  are  latent  and  the  physician  is  first  consulted  for 
copious  and  repeated  vomiting.  The  stomach  is  dilated — there  is  per- 
istaltic unrest- — the  symptoms  are  those  of  pyloric  stenosis.  The  history 
may  possibly  differentiate  between  gastric  and  duodenal  ulcer — but  the 
author  believes  this  result  can  only  be  positively  attained  by  operation, 
which  he  holds  is  invariably  imperative  in  such  cases.  In  this  type  the 
ulcer  is  usually  nearly  healed,  and  the  cicatricial  contraction  is  responsible 
for  the  stenosis.    The  a:-rays  aid  the  diagnosis. 

Perforation. — Perforation  is  the  most  serious  complication  that  can 


Fig. 


311. — Showing  the  disposition  of  the  duodenal  peritoneal  coat,  and  explains 
the  direction  taken  by  duodenal  contents  in  case  of  perforation  (Gaultier). 


occur  with  duodenal  ulcer.  It  may  take  place  in  acute  or  chronic  ulcer, 
both  in  the  young  and  old. 

Finney^  reports  a  case  in  a  child  two  months  old,  while  Moynihan  has 
seen  it  in  a  woman  aged  seventy-seven. 

Sudden  perforation  may  occur  with  the  acute  duodenal  ulcer,  due  to 
burns,  septicemia,  etc. 

Perforation  may  be  acute,  subacute,  or  chronic.  In  Moynihan' s 
series  of  1 1  cases,  acute  perforation  occurred  in  a  chronic  ulcer. 

In  every  case,  there  was  evidence  that  the  ulcer  had  long  been  present, 
but  only  recently  was  the  ulcer  the  seat  of  a  more  active  pathological 
*  London  Lancet,  1908,  ii,  1748. 


SIMPLE    DUODENAL   ULCER 


743 


change,  and  there  had  been  an  exacerbation  in  the  symptoms.     Occasion- 
ally a  perforation  may  occur  without  previous  symptoms. 

Symptoms  of  Acute  Perforation. — There  is  a  sudden  onset  of  intolerable 
and  agonizing  pain.  This  is  so  severe,  that  sudden  death  may  occur  from 
it.  The  patient  is  prostrated,  he  is  pale  and  faint,  the  expression  anxious, 
and  sweat  appears  on  the  brow.  Respirations  are  short  and  quick.  Deep 
inspiration  causes  a  groan  of  agony  and  a  spasm  of  pain.  Replies  to 
questions  are  given  in  snatches  and  expiration  ends  abruptly  in  a  catch. 
Collapse  may  be  complete  in  some  cases,  the  author  finds  in  his  own  ex- 
perience. In  some,  however,  it  may  not 
be  apparent.  When  the  patient  is  seen  ■ 
an  hour  or  two  after  perforation,  at 
which  time  the  pulse  may  not  be  par- 
ticularly rapid,  musctdar  rigidity  is  a 
marked  symptom  and  the  abdomen  is 
at  this  time  retracted.  Distention 
comes  later.  The  tenseness  of  the  ab- 
dominal muscles  is  persistent.  On  over- 
coming the  protective  muscular  rigidity, 
abdominal  tenderness  is  present.  There 
is  an  area  of  more  marked  tenderness 
and  rigidity  to  the  right  of  the  median 
line  above  the  umbilicus. 

Vomiting  may  occur  at  first,  but  it 
usually  does  not. 

The  liver  dulness  is  not  yet  impaired. 
Percussion  of  any  part  of  the  abdomen 
is  resented  by  the  patient. 

As  a  rule,  the  symptoms  rapidly 
alter,  as  fluid  escapes  through  the  rup- 
ture into  the  peritoneal  cavity,  produc- 
ing the  symptoms  of  acute  peritonitis. 

The  pulse-rate  rises  steadily,  the 
quality  becoming  poorer.  The  abdo- 
men, preserving  its  rigidity,  becom.es 
fuller,  until  a  uniform  tight  distention  occurs.  Tenderness,  as  a  rule,  be- 
comes more  marked  on  the  right  side,  and  the  right  iliac  fossa  becomes  the 
most  tender  and  most  distended  region.  Leukocytosis  and  increase  of 
polynuclears  are  present. 

The  temperature,  which  was  previously  normal  or  subnormal,  begins 
to  rise  and  may  reach  io2°F.  or  more.  Intestinal  stasis  is  absolute  from 
the  first.  Repeated  enemata  may  bring  a  little  gas,  and  feces  in  some 
cases.  Interference  with  respiration  persists  and  increases  as  the  ab- 
domen distends.  The  face  becomes  Hvid,  the  face  and  hands  cold  and 
damp,  and,  finally,  cyano?is  develops.  From  the  time  of  perforation  to 
the  death  of  the  patient  a  period  averaging  from  two  to  five  days  may 
elapse. 

The  right  side  of  the  abdomen,  as  heretofore  noted,  is  chiefly  affected, 
so  that  the  mistaken  diagnosis  of  perforative  appendicitis  has  been  fre- 


Fig.  312. — Schema,  after  Moyni- 
han,  showing  direction  taken  by  duo- 
denal contents  in  perforation  of  the 
duodenum;  how  they  arrive  in  the 
region  of  the  cecum  and  simulate 
appendicitis. 


744  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

quently  made.  The  fluid  escaping  from  the  duodenum  is  prevented  from 
passing  to  the  left  by  the  reflection  of  the  great  omentum  from  the  duo- 
denum and  the  stomach.  It  flows  down  to  the  outer  side  of  the  colon 
to  the  right  iliac  fossa  and  brim  of  the  pelvis  and  then  overflows  into  the 
latter.  If  the  ascending  colon  is  bound  down  and  has  no  mesentery,  the 
fluid  may  rise  alongside  the  colon,  crossing  a  few  inches  below  the  hepatic 
flexure,  and  then  flow  to  the  appendix  region,  guided  by  the  obliquity 
of  the  mesentery  (Figs.  311  and  312). 

Differential  Diagnosis  between  Acute  Perforation  of  Duodenal  Ulcer 
and  other  Conditions. — Duodenal  Ulcer. — The  previous  history  of  the 
case  is  of  great  value;  it  occurs  more  frequently  in  men.  Pains  appear 
two  hours  or  later  after  meals.  At  the  time  of  perforation  the  pain  is 
overwhelming  in  character.  It  is  frequently  to  the  right  of  the  median 
line  in  the  epigastrium,  though  it  may  be  referred  to  the  whole  abdomen. 
Within  one  to  two  hours,  however,  the  pain  is  always  of  greater  severity 
on  the  right  side,  and  tenderness  and  muscular  rigidity  are  also  excessive 
there.  The  rigidity  is  extreme.  No  conditions,  except  perforation  of  the 
duodenum  or  stomach,  give  rise  to  such  extreme  tension  in  the  muscles. 
Rigidity  also  persists,  and  retraction  of  the  abdomen  continues  until 
distention  due  to  peritonitis  develops.  Rigidity  does  not  lessen  until 
profound  toxemia  ensues. 

Gastric  Ulcer. — Perforation. — Pain  appears  earlier;  frequently  local 
tenderness,  dorsal  pain,  and  other  symptoms  precede  the  perforation, 
though  not  always  so.  With  perforation  of  the  stomach,  the  pain  is 
usually  to  the  left  of  the  median  line.  After  perforation,  careful  examina- 
tion will  show  an  area  which  is  more  resistant  and  more  tender,  beneath 
which  the  ulcer  lies,  and  hence,  the  site  of  the  perforation.  When  the 
most  tender  area  is  in  the  left  hypochondrium,  the  perforation  is  toward 
the  cardia;  if  around  the  umbilicus,  it  is  in  the  body  of  the  stomach;  and 
if  to  the  right  of  the  median  line  or  in  the  right  hypochondrium,  then 
the  perforation  is  probably  in  the  pyloric  end  of  the  stomach  or  in  the 
duodenum. 

Perforative  Appendicitis. — The  pain  may  be  first  referred  to  the  epi- 
gastrimn  or  to  the  entire  abdomen,  and  then  becomes  localized  in  the  right 
ihac  fossa.  There  may  be  a  dyspeptic  history,  but  not  the  typical  history 
of  gastric  dyspepsia,  as  with  duodenal  ulcer.  There  is  generally  a  history 
of  preceding  pain  in  the  appendical  region,  or  of  previous  attacks,  or  of 
constipation,  or  colitis.  •  In  many  cases  an  aperient  has  been  taken 
previous  to  perforation.  The  muscular  rigidity  with  appendicitis  is  not 
as  intense  as  with  duodenal  perforation,  nor  are  the  pain  and  agony  as 
intolerable.  The  diaphragm  is  not  held  as  tight  and  the  respirations  are 
not  as  short  and  jerky. 

In  both  conditions  there  is  tenderness  in  the  right  iliac  fossa.  Tender- 
ness and  rigidity  are  always  present  in  the  right  hypochondrium  with 
duodenal  perforation,  and  shortly  after  perforation  of  the  duodenal  ulcer, 
rigidity  of  the  right  rectus  (upper  part)  and  tenderness  are  most  marked 
in  this  region. 

With  appendicitis  they  are  exceptionally  there,  and  only  when  the 
appendix  is  retroverted  and  extends  to  the  liver.     Even  then  the  tender- 


SIMPLE   DUODENAL   ULCER  745 

ness  is  less  marked.  Rigidity  of  the  lower  portion  of  the  right  rectus  is 
usual. 

Moreover,  the  test  Head's  zone  for  the  appendix  is  of  value  in  these 
cases,  as  it  lies  below  the  umbilicus.  Rarely  perforation  of  ulcer  and 
perforative  appendicitis  may  coexist.^  At  times,  however,  one  sees  a 
patient  with  general  peritonites,  with  tenderness  most  marked  in  the  right 
iliac  fossa  and  believe  the  condition  due  to  perforated  appendix.  The  his- 
tory may  be  obscure.  On  operation  appendix  is  found  to  be  uninvolved. 
In  such  cases  perforation  of  gall-bladder  or  duodenum  may  be  the  cause. 

Acute  Pancreatitis. — As  a  rule,  there  are  no  initial  symptoms.  Occurs 
more  in  males.  Occasionally  acute  pancreatitis  may  be  dependent  on  the 
impaction  of  a  stone  in  the  ampulla  of  Vater,  in  which  event  there  may  be 
the  previous  history  of  "gall-stones"  or  "gall-stone  dyspepsia."  The  pain 
of  acute  pancreatitis  is  more  in  the  epigastrium.  Muscular  rigidity, 
tenderness,  and  distention  chiefly  occur  there — "an  epigastric  peritonitis" 
— and  the  enlarged  and  edematous  pancreas  may  at  times  be  felt  on  deep 
palpation.  -Fitz  describes  scattered  areas  of  abdominal  tenderness  lying 
probably  over  the  areas  of  fat  necrosis,  and  there  is  tenderness  at  Robson's 
point. 

The  pulse  is  bad  from  the  start,  and  it  is  always  rapid  and  of  poor 
quality.  Its  rate  is  at  first  disproportionate  to  the  severity  of  the  other 
symptoms.  Temperature  is  normal  or  subnormal.  Constipation  is 
marked.  Vomiting  is  frequent  and  obstinate.  It  consists  of  food,  bile, 
and  black  altered  blood.  Blood  is  frequently  passed  from  the  intestines 
and  from  the  other  mucous  membranes,  and  bleeding  may  be  subcu- 
taneous. A  deep  lividity  or  cyanosis  of  the  skin,  chiefly  of  the  face,  occurs. 
Corpulent  people  are  often  attacked  by  acute  pancreatitis,  and  it  occurs 
with  considerable  frequency  during  the  early  months  of  pregnancy. 
Jaundice  may  occur. 

With  acute  pancreatitis,  a  general  distention  of  the  abdomen  is  rare, 
the  right  side  of  the  abdomen  is  not  specially  involved,  and  the  hurried, 
jerky  respiration  due  to  contraction  of  the  diaphragm  does  not  occur. 
Fat  necrosis  is  present  with  acute  pancreatitis.  A  case  of  fat  necrosis 
with  peritonitis  resulting  from  perforation  of  a  duodenal  ulcer  is  reported 
by  Richter^  as  a  rare  occurrence.     The  pancreas  was  found  to  be  normal. 

Acute  Perforation  of  the  Gall-bladder. — The  local  and  general  symptoms 
may  simulate  acute  perforation  of  duodenal  ulcer. 

A  careful  investigation  into  the  previous  history  is  the  only  means  of 
diagnosis.  A  history  of  hepatic  colic,  with  occasional  attacks  of  jaundice, 
can  usually  be  secured.  It  occurs  usually  in  fat  females  of  over  40  years. 
The  previous  paroxysms  of  pain  occur  generally  regardless  of  eating  and 
usually  occur  in  the  right  hypochondrium,  and  pain  may  pass  around 
or  through  the  right  shoulder  blade.  Gall-bladder  may  be  sensitive  to 
pressure,  tender  at  Murphy's  point,  and  the  head  zone  is  present  or  there 
may  be  rigidity  of  the  right  upper  rectus.  There  may  be  tenderness  at 
Boas  point  (posterior  right  side  level  of  10-12  dorsal  vertebrae).  With  a 
previous   acute   inflammation    there    are   leucocytosis,    increased   poly- 

'  B.  Carter,  London  Lancet,   1901,  ii,   1195. 

-  Quarterly  Bulletin  Northwestern  University  Medical  School,  Dec,  1910. 


746  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

nuclears,  temperature  and  at  times  chills.  Jaundice  occurs  in  only  20  per 
cent,  of  cases.  Other  cases  may  only  have  a  sense  of  tightness  or  con- 
striction in  the  epigastric  region,  or  a  feeling  of  stiffness,  or  soreness  in 
the  right  upper  abdominal  quadrant,  while  the  appetite  is  capricious, 
there  is  flatulence  independent  of  food,  and  discomfort  on  an  empty 
stomach.  Any  of  these  premonitory  symptoms  may  occur  or  perforation 
may  occur  suddenly  without  premonitory  symptoms  and  may  be  diffi- 
cult to  differentiate  from  perforation  of  duodenal  ulcer.  The  onset  of 
pain  is  acute.  Some  claim  it  is  not  as  agonizing  as  with  duodenal  ulcer, 
though  I  have  seen  cases  in  which  it  was  fully  equal  and  in  one  apparently 
more  so.  Some  hold  it  is  more  painful  (sudden  rupture  of  a  sac  under 
tension).  Collapse,  prostration  with  rapid  pulse  and  respiration,  sub- 
normal temperature  are  present  at  first;  then  local  rigidity  and  tenderness 
in  gall-bladder  region.  Vomiting  and  intestinal  paresis- — gradual  general 
peritonitis  with  distention,  tenderness  and  rigidity,  most  marked  in  right 
inguinal  region,  as  contents  gravitate  there  just  as  with  duodenal  ulcer 
perforation.  Temperature  rises  with  general  peritonitis,  leucocyto- 
sis,  increased  polynuclears.  Facies  Hippocratica  follows,  cyanosis  and 
death. 

Acute  Thoracic  Disease. — The  mimicry  of  appendicitis  is  more  usual 
than  that  of  perforation  of  ulcer  of  the  duodenum. 

During  the  onset  of  pneumonia,  diaphragmatic  pleurisy  or  acute 
bronchitis,  the  pain  may  be  felt  exclusively  in  the  abdomen,  the  ab- 
dominal muscles  may  be  tense  and  the  surface  tender.  There  are  several 
features  which  are  an  aid  to  differential  diagnosis: 

(i)  The  temperature  in  acute  lesions  of  the  thorax  often  ranges 
higher — 103°  to  io4°F. — than  it  does  in  acute  abdominal  lesions  (rarely 
above  io2°F.). 

(2)  The  respirations  are  more  rapid — 35  to  40  or  more — in  pulmonary 
conditions. 

(3)  There  is  a  disproportion  in  the  early  stages  in  thoracic  lesions, 
between  the  pulse  and  respiration.  The  pulse  may  not  be  much  over 
IOC,  and  the  respirations  35  to  45.  A  more  rapid  pulse-rate,  120  or 
more,  with  a  slower  respiration,  about  25,  would  be  most  frequent  in  an 
abdominal  lesion. 

(4)  In  abdominal  conditions  there  is  persistent  rigidity  and  deeper 
tenderness.  With  thoracic  inflammation  the  tenderness  is  superficial, 
and  deep  pressure  may  even  give  reUef,  and  during  respiration,  at  the 
height  of  expiration,  the  abdominal  muscles  may  be  soft  and  the  rigidity 
absent.  The  rigidity  is  less  marked  and  less  persistent  and  the  area 
affected  is  limited. 

(5)  With  diaphragmatic  pleurisy,  the  respiratory  movements  in  the 
upper  thorax  are  exaggerated,  while  they  are  slower  below. 

(6)  Head's  zones  of  cutaneous  hyperalgesia  for  the  lungs  lie  over  the 
thorax,  while  for  the  duodenum  Head's  zone  lies  just  below  the  free  border 
of  the  ribs,  chiefly  to  the  right  of  the  median  fine,  and  for  the  appendix, 
it  lies  below  the  level  of  the  umbilicus. 

Treatment  of  Acute  Perforation  of  the  Duodenal  Ulcer. — In  brief, 
immediate  operation  is  indicated;  suture  of  perforation,  drainage,  usually 


SIMPLE   DUODENAL   ULCER  747 

gastro-enterostomy.  Subsequent  to  operation,  proctoclysis  in  Fowler's 
position  is  most  valuable.     Resection  of  the  ulcer  may  be  required. 

Subacute  Perforation  of  Duodenal  Ulcer. — In  this  case,  though  there 
is  a  sudden  rupture  of  an  ulcer,  as  in  the  acute  perforation,  there  is  a 
definite  localization  of  the  fluid  escaping  through  the  rent  and  in  many 
instances  a  narrow  circumscribed  peritonitis. 

An  empty  stomach  at  the  time  of  perforation  would  render  the  symp- 
toms less  severe.  A  sudden  movement  or  violent  strain  may  be  the  cause 
of  the  rupture,  A  tag  of  omentum  may  plug  the  opening  of  the  ulcer, 
or  peritoneal  irritation,  as  the  ulcer  deepens,  may  cause  plastic  lymph 
deposits  on  the  base  of  the  ulcer,  so  that  there  is  a  nearly  impenetrable 
barrier  at  the  moment  of  perforation. 

Moreover,  the  duodenum  may  become  adherent  at  the  base  of  the 
ulcer  to  the  anterior  abdominal  wall,  the  liver  or  the  pancreas.  The 
symptoms  are  the  same  as  in  acute  perforation,  except  that  they  are 
less  intense. 

There  is  a  previous  history  pointing  to  duodenal  ulcer;  in  some  cases 
there  is  increased  pain  for  a  few  days  previous  to  perforation,  or  the  ab- 
domen is  stiff  and  sore,  and  discomfort  is  felt  on  laughing  or  stretching. 

The  pain  of  perforation  is  again  sudden  in  its  onset  and  severe  in 
character,  but  not  as  intolerable  as  in  acute  perforation.  Vomiting^  and 
prostration  may  follow.  The  abdomen  is  everywhere  tender;  but  there 
may  be  a  particularly  tender  and  resistant  area,  which  on  palpation  may 
feel  like  a  flat,  hard  mass  inserted  in  the  wall  of  the  abdomen.  Leuko- 
cytosis and  increased  polynuclears  are  present. 

The  symptoms  subside  slowly,  the  character  of  the  pulse  improves, 
vomiting  ceases  and  the  abdomen,  which  was  at  first  hard  and  retracted, 
may  become  soft,  except  at  the  one  spot,  or  it  may  be  slightly  distended, 
with  some  free  fluid. 

If  no  operation  is  undertaken,  there  may  be  several  results,  either  a 
periduodenal  abscess  may  form,  or  a  secondary  rupture  into  the  general 
peritoneum  may  occur,  or  the  adhesion  of  the  ulcer  to  the  abdominal 
wall,  liver  or  pancreas  may  increase  in  firmness,  the  acute  inflammation 
subside  and  the  patient  live  for  years.     This  last  is  more  common. 

Differeniial  Diagnosis  of  Subacute  Perforation  of  the  Duodenum. — 
The  chief  difficulty  is  differentiating  this  condition  from  acute  chole- 
cystitis. In  both  conditions  there  are  paki,  sudden  in  onset,  which  is 
severe  and  often  colicky.  There  is  no  general  invasion  of  the  peritoneum, 
but  a  localized  peritonitis  with  a  tender  resistant  area.  The  best  clue  is 
the  previous  history  of  the  case.  The  determination  of  Head's  zone  may 
be  of  service. 

Treatment. — Since,  in  the  early  stages,  a  differential  diagnosis  between 
acute  and  subacute  perforation  cannot  be  made,  in  view  of  the  uncertainty, 
immediate  operation  is  indicated. 

Chronic  Perforation  of  Duodenal  Ulcer. — In  this  type  of  perforation 

the  intestinal  coat  is  destroyed  slowly  by  the  ulcer,  and  by  the  time  the 

serous  coat  is  reached  a  protective  barrier,  often  reinforced  by  omentum, 

is  raised  by  newly  formed  lymph  deposit  and  adhesions,  so  that  the 

*  There  may  be  blood  in  the  vomitus. 


748  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

inflammatory  process  is  circumscribed  and  perforation  into  the  general 
peritoneal  cavity  does  not  occur,  but  a  local  peritonitis. 

The  local  cavity  increases  in  size  and  the  contents  may  become 
purulent,  so  that  a  periduodenal  abscess  results. 

In  other  cases,  the  perforation  may  occur  suddenly,  but  be  so  minute 
in  size  or  the  duodenum  be  so  empty  that  leakage  is  excessively  small. 
In  this  event,  the  inflammation  may  become  rapidly  circumscribed  by 
adhesions  and  again  a  periduodenal  abscess  result.  Communication 
with  the  duodenum  may  then  be  shut  off  completely,  or  it  may  be  closed 
in  such  a  way  as  to  reopen  when  the  abscess  has  been  opened.  A  duodenal 
fistula  then  results. 

The  periduodenal  abscess  may  perforate,  or  burrow  in  various  direc- 
tions. Fistula  may  be  present  between  the  duodenum  and  the  gall- 
bladder^ or  between  the  duodenum  and  colon^  or  hepatic  abscess^  may 
result;  or  a  pancreatic^  duodenal  fistula. 

A  few  cases  are  also  recorded  of  fistula  between  the  stomach  and 
duodenum;  but  in  these  cases  it  seems  probable  the  primary  ulcer  was  in 
the  stomach.  Subdiaphragmatic  abscess  may  result  from  chronic 
perforation  of  duodenal  ulcer. 

A  periduodenal  abscess  may  burrow  to  a  great  distance;  thus  it  may 
pass  into  the  retroperitoneal  spaces  and  ascend  along  the  greater  vessels 
into  the  neck,  or  may  point  between  the  seventh  and  eighth  ribs  pos- 
teriorly, or  at  the  tip  of  the  right  scapula.  It  has  passed  down  along  the 
ascending  colon  to  the  right  iliac  fossa  and  burst  into  the  cecum  or  may 
lead  to  an  abscess  of  the  right  iliac  fossa  and  pelvis.  It  has  burrowed 
beneath  the  right  psoas  sheath,  causing  flexion  of  hip  and  lordosis.  It 
may  penetrate  the  gall-bladder. 

Meunier^  reports  a  case  where  an  abscess  cavity  was  found  on  the 
imder  surface  of  the  liver.  It  was  traversed  by  the  duodenum,  which 
was  completely  severed  by  a  circular  ulcer. 

The  abscess  which  forms  may  reach  the  anterior  abdominal  wall 
and  pef orate  the  same  with  resulting  external  duodenal  fistula.®  These 
cases  ultimately  die  of  inanition  and  sepsis  unless  definite  surgical 
procedures  are  adopted. 

Treatment. — Appropriate  surgical  measures  are  indicated  for  chronic 
perforation  of  a  duodenal  ulcer. 

Differential  Diagnosis  of  Duodenal  Ulcer. — This  matter  is  so  important 
that  it  is  deemed  proper  to  recapitulate  some  former  observations. 

Constriction  of  the  Duodenum  due  to  Abnormal  Folds  of  the  Anterior 
Mesogastrium. — This  condition  is  a  constriction  of  the  second  portion 
of  the  duodenum  due  to  the  remains  of  a  definite  embryological  structure. 
Six  cases  are  reported  by  Harris.^  There  are  disturbances  of  digestion, 
distress  in  the  epigastric  region  usually  two  to  three  hours  after  eating. 

*  London  Lancet,  1850,  i,  776;  Schmidt's  Johrbuch,  cxxxix,  293. 

*  Pathol.  Soc.  Trans.,  1862,  xiv,  173. 

'  Munch,  med.  Wochens.,  1887,  i,  678. 

*  Guy's  Hosp.  Museum,  No.  757. 

*  BuU.  Soc.  Anat.,  1893,  Ixviii,  487. 

8  Archiv  Gen.  de  Med.,  1887,  i,  414  et  seq.;  also  Bull.  Soc.  Anat.,  1870,  xv,  439. 
^Journal  A.  M.  A.,  April  18,  1914. 


SIMPLE   DUODENAL   ULCER  749 

There  are  attacks  of  sharp  pain  in  the  right  epigastric  or  hypochondriac 
region.  Distress  is  described  as  a  sensation  of  pressure  in  the  stomach. 
Tenderness  in  the  epigastrium  is  present  to  some  degree.  Nausea  oc- 
casionally occurs,  but  seldom  vomiting.  Chronicity  is  characteristic, 
the  trouble  often  dating  from  early  life.  Though  there  are  more  or  less 
intermissions  during  the  early  history,  the  symptoms  become  practically 
continuous  after  they  are  well  established.  Hyperchlorhydria  is  always 
present.  Thus  it  differs  from  chronic  duodenal  ulcer  where  with  symp- 
toms of  hyperacidity,  hypochlorhydria  is  generally  present.  No  occult 
blood  in  the  stools.  The  attacks  of  pain  in  the  right  hypochondriac  region 
with  slight  jaundice  in  two  cases  suggested  gall-stones.  There  were  ab- 
sence of  marked  intermissions  with  relapses  such  as  occur  with  ulcer. 
The  radiograph  is  of  great  diagnostic  value.  The  head  (first  part  of  the 
duodenum)  is  long,  large  and  dilated  and  often  part  of  the  second  portion, 
with  a  fixed  point  at  the  right  of  the  constriction.  Congenital  stenosis 
of  the  duodenum^  in  an  adult  has  also  been  reported  and  also  other 
varieties  of  duodenal  stenosis. 

Stricture  of  the  duodenum  due  to  inflammatory  adhesions,  or  cicatricial 
contraction  may  also  occur  and  in  some  cases  closely  simulating  duodenal 
ulcer.  In  one  patient  of  the  author's,  the  pain  occurred  at  the  usual  time 
as  with  duodenal  ulcer,  there  was  epigastric  tenderness,  but  the  gastric 
analyses  showed  hyperchlorhydria,  while  with  chronic  duodenal  ulcer, 
the  symptoms  are  those  of  hyperchlorhydria,  with  frequently  hypo- 
chloi-hydria  present.  No  occult  blood  was  present  in  the  stool  at  any  time. 
The  radiograph  demonstrated  a  bismuth  deposit  in  the  duodenum  and 
partial  stenosis^  of  the  transverse  colon  from  adhesions.  Operation  by 
Wm.  P.  Healy  showed  a  stenosing  band  about  the  transverse  colon.  It 
passed  upward  and  slightly  constricted  the  duodenum.  Above  this  the  bis- 
muth deposit  occurred.  There  was  no  ulcer.  Usually  the  duodenum  is  some- 
what dilated.  In  stenosis  cases  of  marked  type,  the  stomach  is  also  dilated 
and  the  symptoms  in  that  event,  point  more  to  benign  pyloric  stenosis. 

Duodenal  Ulcer. — This  condition  is  more  frequent  in  males;  pain  after 
food  does  not  appear  until  two  hours  or  more;  the  hunger  pain  is  relieved 
by  food;  pain  may  be  in  the  median  line,  though  quite  frequently  it  is 
to  the  right  of  it,  and  may  radiate  over  the  right  costal  margin  to  the 
breast  or  round  to  the  back.  Tenderness  on  pressure,  when  present,  is 
always  to  the  right  of  the  median  line.  It  is,  as  a  rule,  not  as  circumscribed 
as  with  gastric  ulcer.  Attacks  are  apt  to  be  recurrent  in  the  cold  and  wet 
seasons.  Vomiting  is  rare,  unless  there  is  stenosis  of  the  duodenum  or 
pylorus.  Helena  more  usually  occurs  without  hematemesis;  hemorrhage 
is  more  dangerous;  perforation  more  frequent;  latent  type  with  sudden 
hemorrhages  is  more  frequent;  history  is  usually  chronic,  symptoms  recur 
in  attacks;  patients  complain  of  hyperacidity.  Gastric  findings,  usually 
in  chronic  cases,  show  no  excessive  content  of  HCl,  in  fact,  as  a  rule,  it 
is  less  than  normal.  On  the  other  hand,  in  the  cases  with  brief  history 
and  acute  hemorrhage,  I  have  generally  found  hyperchlorhydria.  These 
last  are  of  easy  diagnosis.  In  the  more  obscure  cases  repeated  examina- 
tions of  the  stool  for  occult  blood  will  usually  show  its  presence.     The 

1  Terry  and  Kilgore,  Journal  A.  M.  A.,  June  3,  1916. 

*  The  deposit  was  present  in  the  cap  and  in  the  descending  duodenum. 


750  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

gastric  contents  show  no  pus,  and  at  times  blood  or  occult  blood  is  present. 
The  presence  of  pus  shows  an  ulceration  in  the  pylorus  or  stomach.  The 
determination  of  occult  blood  in  the  stool,  in  cases  where  there  is  no  definite 
history  of  hemorrhage  or  visible  evidences  of  the  same,  is  of  great  im- 
portance. In  an  obscure  case  a  positive  diagnosis  of  duodenal  ulcer  was 
made  chiefly  on  this  point  and  was  confirmed  at  operation  by  Herman 
Haubold.  It  served  to  exclude  gall-bladder  disease  and  a  gastric  neurosis. 
Radiographs  were  objected  to  by  this  patient,  though  not  operation.  The 
special  Head  zone  aids  differentiation  of  ulcer  of  the  duodenum  from 
disease  of  the  gall-bladder  and  stomach. 

Gastric  Ulcer. — This  is  more  frequent  in  women,  is  frequent  with 
chlorosis;  pain  is  earlier,  within  a  short  time  or  less  than  an  hour  after 
food,  rarely  within  one  to  two  hours;  pain  in  the  median  line  or  to  the  left 
and  may  radiate  to  the  left  margin,  left  breast,  and  even  down  the  left 
arm;  dorsal  pain  is  present  at  a  point  between  the  scapula  and  spine; 
tenderness  is  more  circumscribed  and  is  in  the  median  line  and  often  to 
the  left  of  the  same;  there  is  not  the  same  dependence  of  the  attacks  on 
the  climate  or  seasons;  vomiting  is  more  frequent;  hematemesis  more 
frequent;  melena  less  so,  but  quite  often  present;  hyperchlorhydria  is 
present  in  the  acute  cases;  diminished  acidity  or  absence  of  HCl  may  occur 
in  the  chronic  ulcers. 

Pus  {microscopic)  always  present  in  the  gastric  contents;  occult  blood  or 
blood  is  found  in  the  gastric  contents.  Pus  is  extremely  important,  as 
in  a  case  of  Connor's,  the  diagnosis  was  made  from  its  presence  alone,  no 
occult  blood  being  found.  Occult  blood  in  the  stool  is  frequent.  No 
mucus  is  present  in  the  gastric  contents. 

Bassler  holds  that  2  per  cent,  or  more  of  gas  in  hyperchlorhydria  is 
suspicious  of  ulcer. 

Duodenal  ulcer  has  also  been  mistaken  for  chronic  appendicitis,  since 
the  latter  may  cause  hyperacidity  with  pylorospasm  and  symptoms 
pointing  to  the  duodenum  without  ulcer  being  present.  Lewisohn 
reports  four  cases  believed  to  be  chronic  appendicitis  in  which  duodenal 
ulcer^  was  apparently  the  lesion.  Frankly  if  proper  ic-ray  examination 
has  previously  been  carried  out  and  the  duodenum  is  carefully  explored, 
I  can  see  no  reason  for  such  an  error. 

Simple  Hyperchlorhydria. — This  is  a  very  frequent  condition — con- 
tent of  HCl  is  always  high  and  constitutes  chief  acidity — total  acidity  is 
usually  high  though  mild  cases  occur.  No  pus  in  gastric  contents  and  no 
blood  or  occult  blood.  No  occult  blood  is  found  in  the  stool.  There  is  no 
special  predilection  for  either  sex.  Dietary  indiscretions,  anemia,  gas- 
troptosis,  nervous  conditions,  etc.,  may  be  the  cause.  Cases  may  be 
persistent,  but  are  amenable  to  relief  by  treatment.  When  hyperchlor- 
hydria occurs  with  other  conditions,  such  as  appendicitis,  gall-bladder 
disease,  and  gastric  or  duodenal  ulcer,  the  anamnesis  and  physical  ex- 
amination for  the  first  two  conditions  and  the  presence  of  gastric  and  in- 
testinal occult  blood  with  the  last  two  will  aid  diagnosis.  With  the  ulcer- 
ated^ conditions,  gall-bladder  disease  and  appendicitis,  special  Head  zones 
are  present.     There  is  no  mucus  with  simple  hyperchlorhydria. 

*  Medical  Record,  June  17,  1916. 

*  The  a:-rays  will  exclude  ulcer. 


SIMPLE   DUODENAL   ULCER  75 1 

Acid  Gastritis. — There  is  hyperacidity  plus  mucus.*  It  is  an  initial 
stage  of  chronic  gastritis. 

Achlorhydria  Hemorrhagica  Gastrica. — There  are  absence  of  free  HCi, 
presence  of  mucus,  many  actively  growing  bacteria,  pus,  blood,  or  occult 
blood.  The  condition  is  reflex.  Gall-bladder  disease  or  appendicitis 
are  a  frequent  cause  and  the  condition  is  relieved  by  operation. 

Cholelithiasis. — There  are  no  definite  attacks  which  occur  at  certain 
seasons  (no  periodicity);  the  pain  is  unendurable;  is  more  severe  than 
duodenal  ulcer,  except  when  there  is  perforation,  which  last  has  associated 
definite  symptoms.  Pain  occurs  within  an  hour  after  food.  There  are 
often  a  "catch  in  the  breath,"  depression,  nausea,  and  sweating.  The 
pain  begins  suddenly,  is  abrupt  in  the  onset  and  in  its  relief,  as  it  may 
rapidly  pass  away;  acidity  or  heartburn  may  be  present. 

Food  or  an  alkali  does  not  relieve  the  pain  and  the  idea  of  food  is 
repugnant.  Chills,  sweats,  a  "feeling  of  gooseflesh,"  shivering,  and  sub- 
sequent heat  are  present.  There  may  be  a  sensation  of  pain  in  the 
shoulder-blade,  which  is  suggestive  of  gall-stone  impaction  in  the  cystic 
duct.  The  pain  is  cramp-like,  passes  through  and  around  the  right  side 
to  the  shoulder-blade,  and  epigastric  distention  accompanies  it.  A  feeling 
of  stiflfness  or  soreness  remains  for  some  hours.  The  gall-bladder  is  tender 
and  Head's  zone  is  present,  also  Boas  point  of  tenderness. 

Ulceration  of  a  Gall-stone  into  tJie  Diiodenwn. — The  writer  has  seen  a 
case  suffering  from  an  attack  of  acute  pain  to  the  right  of  the  median  line 
in  the  epigastric  region,  followed  by  several  attacks  of  hematemesis  and 
marked  melena.  One  consultant  believed  it  due  to  hemorrhage  from  an 
occult  duodenal  ulcer.  The  patient  was  a  stout,  elderly  woman,  with  an 
apparent  history  of  previous  gall-stone  attacks.  The  possibility  of  sub- 
acute pancreatitis  with  hemorrhage  was  suggested.  Subsequently  a  gall- 
stone the  size  of  an  English  walnut  was  removed  from  the  intestines.  It 
had  ulcerated  through  from  the  gall-bladder,  eroding  a  large  vessel. 
The  patient  recovered. 

Chronic  Pancreatitis,  Simulating  Gastric  or  Duodenal  Ulcer,  with  Symp- 
toms of  Pyloric  Stenosis,  Moderate  Dilatation  of  Stomach. — This  condition 
is  particularly  interesting.  The  writfer  recently  examined  a  case  (female) 
for  John  Connors  presenting  the  following  symptoms:  pain  one  to  three 
hours  after  eating;  tenderness  in  the  epigastrium;  occasional  vomiting; 
history  of  apparent  cofifee  grounds;  complains  of  hyperacidity,  but  acidity 
and  HCI  within  normal  limits,  three  years'  history;  stomach  dilated  to 
umbilicus;  no  pus;  no  occult  blood  found  in  gastric  contents;  no  occult 
blood  in  stool  (two  examinations).  The  writer  found  evidences  of 
mechanical  obstruction  to  the  exit  of  gastric  contents.  In  view  of  ab- 
sence of  pus  and  occult  blood  in  the  same,  believed  obstruction  to  be 
Oft  the  duodenal  side,  and  probably  due  to  ulcer.  Stool  showed  some  dis- 
turbance of  intestinal  functions,  but  chronic  pancreatitis  was  not  sus- 
pected. Laparotomy  showed  no  ulcer,  hut  mechanical  obstruction  to  the 
duodenum  from  an  enlarged  head  of  the  pancreas;  also  a  chronic  pancrea- 
titis, no  obstruction  to  the  common  bile-duct,  and  no  gall-stones.  The 
common  bile-duct  evidently  lay  outside  the  enlarged  head  of  the  pancreas. 
The  gall-bladder  was  opened  and  drained.  It  contained  no  gall-stones, 
^  These  are  demonstrated  by  gastric  analysis.    There  is  no  gastric  mucus  with  ulcer. 


752  DISEASES    OF    THE    STOMACH   AND ,  INTE-STINES 

but  thick  inspissated  bile.  This  case  is  of  particular  interest.  Whether 
subsequent  to  operation  the  enlarged  head  will  subside  or  gastro-enter- 
ostomy  will  be  necessary,  it  is  too  soon  to  determine.  Patient  is  doing 
well. 

Banti's  Disease. — The  anamnesis  and  the  presence  of  the  enlarged 
spleen  are  an  important  aid  to  diagnosis. 

One  should  also  determine  that  cirrhosis  of  the  liver  particularly  in 
syphilitics  is  not  a  factor  in  gastro-intestinal  hemorrhage  and  that  the  patient 
is  not  a  "bleeder." 

I  have  recently  seen  a  most  interesting  case  of  persistent  intestinal 
hemorrhage  with  indefinite  gastro-intestinal  symptoms  of  four  years' 
duration,  in  which  duodenal  ulcer  was  believed  to  be  the  cause.  Opera- 
tion by  Meeker  at  the  Red  Cross  Hospital  showed  a  single  male  lumbricoid 
worm  1 1  inches  long  in  the  jejunum — i  foot  below  the  duodenum.  There 
were  evidences  of  numerous  perforations  of  the  intestinal  mucosa,  with 
resulting  hemorrhages.  No  eosinophilia  was  present,  and  no  other  worms 
or  ova  were  found.  The  worm  was  coiled  into  a  U  and  was  very  active. 
This  is  the  first  such  case  I  beHeverecordedof  a  lumbricoid  worm  producing 
intestinal  hemorrhage,  though  it  has  occurred  with  ankylostoma. 

Prognosis. — The  prognosis  is,  as  a  rule,  quite  serious,  especially  in 
the  cases  with  frequent  recurrent  hemorrhage.  Perforation  requires 
immediate  surgical  procedure.  Relapses  may  occur  in  the  apparently 
cured  cases,  but  I  have  seen  perfect  recovery  follow  proper   treatment. 

Treatment. — This  is  similar  to  ulcer  of  the  stomach. 

Hemorrhage. — For  acute  hemorrhage,  apply  an  ice-bag  to  the 
epigastrium  and  give  at  once  a  hypodermic  of  morphin,  yi  grain  (0.016). 

Tremoliere's  solution,  calcium  chlorid  (2  per  cent,  solution)  in  gelatin 
(5  per  cent,  solution),  i  ounce  (30.0)  every  two  to  three  hours  by  mouth, 
is  useful.  Gelatin  (5  to  10  per  cent.),  by  mouth,  i  ounce  (30.0),  or  a  2 
per  cent,  solution  subcutaneously  may  be  employed;  calcium  chlorid  or, 
preferably,  calcium  lactate,  10  grains  (0.6)  in  4  ounces  (125.0)  of  water 
every  three  hours  by  mouth,  or  by  enema  if  vomiting,  or  strontium  or 
magnesium  lactate  by  hypodefmoclysis,^  15  to  30  grains  (1.0-2.0)  in  4 
ounces  (125  c.c.)  of  sterile  water,  or  ernutin,  5  minims  (0.296)  by  hypo- 
dermic, are  all  useful.     Emetin  in  gr.  ^^  doses  has  been  advocated. 

Adrenalin  (i  :  1000),  5  minims  (0.296)  or  more,  has  been  recommended 
by  mouth  or  by  hypodermic.  It  may  too  markedly  raise  pulse  tension. 
Normal  horse-serum  or  human  serum  by  mouth  or  the  latter,  preferably 
by  hypodermic,  15  to  30  c.c,  might  prove  of  value. 

Spriggs^  advocates  the  use  of  oHve  oil  or  almond  oil,  as  suggested  by 
Cohnheim  and  Walko.  He  gives  3.^  to  i  ounce  (30.0-60.0)  t.i.d.,  in- 
creasing the  dose  to  2  ounces  (^120  c.c.)  in  some  cases.  Spriggs  often 
starts  the  treatment  by  giving  the  olive  oil  alone  by  mouth  every  three 
hours,  and  nothing  else  except  water  for  the  thirst.  This  method  is 
continued  until  the  blood  disappears  from  the  stool.  He  then  gives 
cream,  and  the  foods  of  the  Lenhartz  diet  are  added,  excluding  rice.  The 
oil  is  then  reduced  to  i  dram  (4.0)  before  each  meal. 

Author's  Method. — The  author  advocates  the  ice-bag,  morphin  by 

^  The  calcium  salts  may  also  be  given  for  long  periods  by  protoclysis. 
2  Brit.  Med.  Jour.,  May  21,  1910. 


SIMPLE    DUODENAL   ULCER  753 

hypodermic,  lactate  of  calcium,  10  grains  every  three  hours  in  4  ounces 
(125.0)  of  water,  and  i  ounce  (30.0)  of  a  5  to  10  per  cent,  gelatin  solution 
every  three  hours;  ernutin,  5  minims  (0.296)  by  hypodermic,  is  useful, 
and  in  severe  cases  the  serum  treatment  by  mouth  or  hypodermic. 

In  a  recent  case  with  a  tendency,  to  vomit,  the  lactate  of  calcium  was 
first  given  by  rectum.  After  two  doses  it  was  not  retained.  Lactate 
of  calcium,  15  grains  (i.o),  was  then  dissolved  in  6  ounces  (185  c.c.)  of 
water  and  dram  doses  of  this  given  every  half  hour,  with  similar  doses  of 
5  per  cent,  gelatin  solution,  i  dram  (4.0)  each.  The  result  was  most 
successful.  The  lactate  of  calcium  may  also  be  given  by  proctoclysis — 
60  grains  in  one  quart  of  water — rate  60  drops  to  the  minute.  This  is  par- 
ticularly valuable  if  there  is  vomiting.  Nourishment  can  be  administered 
at  the  same  time. 

Olive  oil,  I  ounce  (30.0),  in  which  bismuth  subnitrate,  i  dram  (4.0), 
is  suspended,  may  aid  in  coating  the  bleeding  surface.  With  a  persistent 
hemorrhage,  surgical  procedure  may  be  indicated,  and  it  is  certainly 
called  for  in  persistent  recurrent  hemorrhages. 

For  collapse,  rectal  normal  saline  enemata  at  i2o°F.,  a  pint  to  a  quart, 
proctoclysis,  or  hypodermoclysis  are  indicated.  Rarely  saline  or  mediate 
infusion  may  be  required.  In  one  case  the  writer  needled  a  superficial 
vein  and  injected  saline  solution  by  this  method.  Camphorated  oil, 
5  grains  (0.3)  camphor  in  20  drops  of  almond  oil,  repeated  every  hour  for 
several  doses,  and  strychnin  sulphate,  J^q  to  ^^q  grain  every  three  hours, 
may  be  required.  During  the  stage  of  collapse  rectal  feeding  is  indicated. 
White  of  egg  and  gelatin  solution  (cold)  may  be  given  by  mouth.  They 
take  up  free  acid  and  the  latter  tends  to  check  hemorrhage. 

Diet. — Unless  collapse  be  present,  the  author's  modification  of  the 
Lenhartz  method  of  diet  the  writer  believes  most  efficacious,  to  be  begun 
directly  after  hemorrhage,  if  it  has  occurred.  This  relieves  best  the  hunger 
pain  and  takes  up  the  free  HCl.  The  patient  should  remain  in  bed  and 
the  general  method  of  treatment  followed  as  with  gastric  ulcer. 

Hyperchlorhydria  if  present  should  be  treated,  and  it  is  advisable, 
even  if  the  HCl  be  less  than  normal  but  in  fair  amount,  to  administer 
an  alkali,  such  as  milk  of  magnesia,  magnesia  usta  or  soda  bicarbonate, 
since  the  patient  complains  of  acidity  and  evidently  there  is  some  irritant 
action  from  the  acid. 

Iron  and  arsenic  should  be  given  for  the  anemia  caused  by  hemorrhage. 

The  bismuth  treatment  should  be  followed  out,  with  which  the  silver 
nitrate  may  be  alternated,  as  in  gastric  ulcer. 

The  medical  treatment  should  he  tried  for  the  first,  or  even  second, 
attack.  I  have  given  one  patient  recently  the  benefit  of  the  doubt.  He 
had  a  duodenal  ulcer  with  two  hemorrhages  a  year  apart.  I  advised 
medical  treatment  for  the  present  with  careful  watching,  and  a  resort  to 
surgery  if  furthur  hemorrhage  ensued. 

An  acute  attack  with  marked  hyperchlorhydria,  as  in  the  similar 
type  of  acute  gastric  ulcer,  seems  most  amenable  to  medical  treatment 
unless  there  be  dangerous  hemorrhage,  or  perforation. 

Surgery. — ^^With  the  above  exception,  when  a  series  of  attacks  have 
occurred,  surgical  procedure  is  indicated,  as  in  no  other  way  can  the 
48 


754  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

chronic  ulcer  be  cured.     The  type  of  operation  depends  on  the  conditions 
found,  and  the  methods  are  as  follows: 

1.  Excision  of  the  ulcer.  Simple  excision.  Finney's  operation. 
Excision  should  be  practised  when  the  ulcer  is  small  and  the  gut  is  not 
narrowed  by  the  operation. 

2.  Gastro-enterostomy.  Infolding  the  ulcer,  so  as  to  narrow  the  lumen 
of  the  gut  a.nd  prevent  the  exit  of  food  through  the  pylorus,  should  be  carried 
out  at  the  same  time.  If  obstruction  is  already  present  from  contraction 
of  the  ulcer,  then  infolding  is  unnecessary. 

3.  Resection  of  the  duodenum  with  or  without  the  pyloric  portion  of 
the  stomach. 

4.  Resection  and  end-to-end  anastomosis,  the  pylorus  being  left 
intact.  Posterior  gastrojejunostomy  is  the  best  operation.  Anterior  gastro- 
enterostomy, Roux's  operation,  or  Moynihan's  modification  may  be 
required. 

Stenosis  with  Motor  Disturbances  and  Dilatation  of  the  Stomach. — 
Stenosis  of  the  duodenum  near  the  pylorus  or  at  the  pylorus,  from  con- 
traction and  connective-tissue  formation  from  an  ulcer,  produces  dila- 
tation of  the  stomach  with  marked  disturbance  in  motility,  vomiting, 
peristaltic  unrest,  etc.  All  cases  of  organic  stricture  are  surgical  and 
gastro-enterostomy  is  indicated  under  such  conditions. 

Acute  and  subacute  perforation  require  immediate  operation.  With 
chronic  perforation  (periduodenal  abscess),  whether  localized  or  whether 
it  has  burrowed,  the  abscess  should  be  freely  opened.  These  patients 
often  remain  with  a  duodenal  fistula  and  die  from  inanition,  unless  further 
surgical  procedure  is  undertaken.  Gastro-enterostomy  in  such  event 
is  indicated  and  with  it  an  infolding  at  the  pylorus^  or  of  the  stomach 
in  front  of  the  pylorus,  so  that  food  is  thus  compelled  to  pass  through 
the  new  opening  and  can  no  longer  escape  through  the  duodenal  fistula. 

Adhesions  and  obstructive  jaundice  require  operation. 

If  the  patient  have  recurrent  large  hemorrhages  and  be  apparently 
bleeding  to  death,  operation  is  at  once  indicated. 

Intestinal  Ulcers  from  Cutaneous  Burns 

Ulcers  from  extensive  burns  (cutaneous)  generally  occur  in  the  upper 
transverse  duodenum,  seldom  lower  down.  Rarely  an  ulcer  may  occur 
in  the  stomach  or  other  part  of  the  intestines.  There  may  be  a  single 
ulcer  or  five  or  six  of  them.  There  is  considerable  loss  of  tissue  in  some 
cases,  in  others  erosions,  and  at  times  inflammation  of  the  mucous 
membrane.  The  shape  of  the  ulcer  is  irregular  and  dentate  or  long  and 
narrow. 

The  course  is  very  acute,  the  result  generally  fatal;  hemorrhage  or 

perforation  occurring  within  one  to  two  weeks  after  the  burn  or  even 

within  two  to  three  days.     The  condition  is  probably  due  to  septic 

embolism.     Operate  if  there  is  perforation.     In  mild  cases  the  treatment 

is  that  of  duodenal  ulcer.     Intestinal  hemorrhage  and  local  tenderness 

are  the  salient  symptoms. 

^  Division  at  the  pylorus  and  suture  of  the  stomach  and  duodenum  with  gastro- 
enterostomy may  be  substituted. 


SIMPLE   DUODENAL   ULCER 


755 


Embolic  and  Thrombitic  Ulcers     • 

Parenski^  first  described  this  condition.  These  ulcers  originate  from 
emboli,  which  are  carried  into  the  small  branches  of  the  mesenteric  arteries 
from  an  endocarditis  or  atheromatous  degeneration  of  the  aorta,  from  an 
abscess  focus  or  foci,  or  from  thrombosis,  as  a  result  of  endarteritis. 
They  occur  in  the  jejunum,  ileum,  colon,  and  also  in  the  duodenum. 
If  the  embolus  is  aseptic,  infarction  with  hemorrhagic  infiltration  occurs 

and  necrosis  results,  with  the  pro- 
duction of  an  ulcer.  The  ulcers,  as  a 
rule,  are  small,  circular,  or  irregular 
in  outline.  Occasionally  the  whole 
thickness  of  the  intestines  may  be- 
come involved,  so  that  peritonitis  of 
a  fibrinous  or  purulent  type  occurs, 
or  at  times  perforation.  These  ulcers 
occur  in  the  area  of  distribution  of 
the  occluded  vessels. 

Infarction  of  the  spleen  and  kid- 
neys may  be  present.  If  the  emboli 
are  septic,  numerous  small  abscesses 
are  seen  in  the  submucosa,  which 
may  break  down  and  form  ulcers. 
These  conditions  may  result  from 
sepsis,  acute  appendicitis,  etc.  Hem- 
orrhage may  occur  as  a  result.     In 


Fig-  313-- 


-A,   Ulcer  of  duodenum  secondary  to  appendicitis;   B,  primary  diseased 
appendix. 


Fig.  313  is  shown  such  a  case,  the  duodenal  ulcer  resulting  from  acute 
appendicitis. 

Small  nodules  (miliary  abscesses),  consisting  of  round  cells  surrounding 
a  blood-vessel,  are  at  times  found  postmortem  in  fatal  cases,  not  yet  having 
broken  down  into  ulcers.  Colicky  pains,  tenderness,  diarrhea  with  blood 
and  pus,  occurring  in  cases  in  whom  embolic  processes  can  be  discsovered 
in  other  organs,  or  when  a  cause  for  emboli  can  be  found,  render  the 
diagnosis  of  embolic  ulcer  probable. 

1  Wiener  med.  Jahrbvicher,  1876,  Heft.  3. 


756 


DISEASES  OF  THE  BLOOD-VESSELS 


become  extreme — mucous,  watery,  and  at  last  bloody — or  an  intestinal 
hemorrhage  may  occur  at  the  commencement,  with  dark-brown  or  tarry 
stools,  which  at  times  may  have  a  fetid  odor.  The  blood  may  not  always 
be  voided,  but  retained,  and  the  patient  may  have  the  symptoms  of 
hemorrhage — collapse,  cold  extremities,  rapid  and  feeble  heart,  and 
subnormal  temperature. 

In  the  other  type  of  cases  the  patient  may  have  signs  of  acute  in- 
testinal obstruction;  a  history  of  constipation  for  some  days;  distended 
and  painful  abdomen;  vomiting,  at  times  feculent;  severe  abdominal 
pains;  collapse  and  peritonitis.  The  attack  is  clearly  due  to  intestinal 
paralysis. 

Sprengel  groups  the  cases  according  to  their  pathological  causes: 
First,  hemorrhagic  infarct;  second,  anemic  gangrene.  Under  the  first 
group,  one  would  expect:  Bloody  ejections  per  rectum  or  os;  serohemor- 
rhagic exudate  in  the  peritoneal  cavity;  thickening  of  the  intestinal  wall, 
due  in  part  to  hemorrhage;  gradual  paralysis  of  the  intestine;  late  peri- 
tonitis, local  or  diffuse.  Under  the  second  group  (anemic  gangrene): 
Early  paralysis  of  the  intestinal  walls  from  local  necrosis,  early 
obstruction  (early  distention  of  abdomen,  following  distention  of  afferent 
gut) ;  early  peritonitis,  diffuse  or  local,  depending  also  on  the  occurrence 
of  early  or  late  perforation;  inflammatory  exudate  in  the  peritoneal 
cavity;  all  these  symptoms  can  also  be  met  with  in  acute  invagination 
and  in  other  forms  of  acute  obstruction. 

Diagnosis. — The  following  may  be  of  service:  An  intestinal  hemor- 
rhage from  no  apparent  cause :  colicky  pains  of  great  severity,  tympanites 
and  tenderness;  evidences  of  effusion  into  the  peritoneal  cavity;  the 
discovery  of  simultaneous  embolism  in  other  vessels  or  of  an  endocarditis. 
In  many  cases,  however,  the  salient  symptoms  are  not  all  present;  and 
in  the  type  simulating  obstruction  the  true  cause  cannot  be  determined. 

Prognosis. — This  is  generally  fatal  in  occlusion  of  the  superior  mes- 
enteric artery.     In  rare  instances  recovery  may  be  possible. 

Treatment  will  be  described  at  the  end  of  the  chapter. 

Embolism  and  Thrombosis  of  the  Inferior  Mesenteric  Artery. — 
In  83  cases  of  Gerhardt,  in  only  five  instances  was  the  inferior  mesen- 
teric artery  obstructed;  in  four  cases  by  emboli  and  in  one  by  thrombosis; 
and  in  two  of  these  the  superior  mesenteric  artery  was  also  obstructed. 
This  condition  is  rare. 

Symptoms. — The  chief  symptoms  are  pain,  tenesmus,  and  bloody 
stools.  Gerhardt  states  that  the  blood  is  bright  red  and  that  in  ob- 
struction of  the  superior  vessel  it  is  darker,  but  I  believe  it  generally 
dark  unless  from  lower  sigmoid  or  rectum.  The  descending  colon,  sig- 
moid, and  rectum,  or  parts  of  these  are  affected,  the  mucosa  becoming 
red,  succulent,  and  containing  effusions  of  blood.  The  mucous  membrane 
may  be  loose  and  detached  in  places  and  hemorrhagic.  There  are  not 
the  serious  lesions,  as  a  rule,  as  in  occlusion  of  the  superior  mesenteric 
artery.  The  artery  (inferior  mesenteric)  is  not  an  end  artery  functionally, 
and  the  circulation  is  generally  re-established.  Rarely  there  may  be 
infarction  or  gangrene  with  perforation. 


SIMPLE    DUODENAL   ULCER  757 

may  also  be  a  cause.  The  meat  of  tuberculous  cattle  probably  plays 
a  lesser  role,  as  it  is  generally  thoroughly  cooked.  There  is  no  reason 
why  other  raw  food  products  may  not  be  occasionally  a  source  of  infec- 
tion, especially  if  exposed  to  infection  by  flies  or  sources  of  contamination. 
In  adults  primary  intestinal  tuberculosis  is  rare  (in  the  Munich  Pathologic 
Institute  i  in  1000  cases).  The  lower  ileum  is  usually  first  involved  and 
then  the  rest  of  the  small  intestine  and  colon. 

Sjmiptoms. — The  condition  may  begin  with  irregular  diarrhea,  slight 
fever,  and  coUcky  pains.  Rarely,  hemorrhage  may  be  the  first  symp- 
tom. At  first  the  symptoms  may  simulate  a  chronic  catarrh.  Until 
subsequent  emaciation  becomes  marked  or  an  involvement  of  the  lungs 
occurs,  the  condition  may  not  be  suspected.  The  stools  in  every  doubtful 
case  should  be  examined  for  Koch's  tubercle  bacillus,  which  is  diagnostic. 
The  tuberculin  test,  by  injection  or  by  the  ocular  method,  should  be 
made. 

A  deceptive  condition  is  when  the  ulceration  begins  in  the  cecum, 
and  there  are  symptoms  suggestive  of  appendicitis,  with  tenderness  in 
the  right  iliac  fossa,  constipation,  or  irregular  diarrhea.  Osier  reports, 
in  his  primary  cases  of  intestinal  tuberculosis,  occasional  fatal  hemorrhage 
or  perforation,  with  the  formation  of  pericecal  abscess  or  perforative  peri- 
tonitis, or,  rarely,  partial  healing,  with  great  thickening  of  the  intestinal 
walls  and  narrowing  of  the  canal  (chronic  hyperplastic  tuberculosis). 

Secondary  Tubercular  Ulcers  of  the  Intestines  (Tuberculosis) 

These  are  very  common  in  chronic  pulmonary  tuberculosis. 

Frerichs^  found  tuberculosis  of  the  ileum  in  80  per  cent,  of  these 
cases.  In  566  of  1000  Munich  autopsies  secondary  tuberculosis  was  found 
in  the  ileum,  cecum,  or  colon,  and  in  all  but  three  the  lungs  were  in- 
volved.    Swallowing  tuberculous  sputum  is  the  cause. 

The  lowest  part  of  the  ileum  is  the  chief  point  of  infection  with  ulcers. 
It  often  extends  to  the  cecum,  colon,  or  rectum,  and  upward  to  the 
jejunum  or  even  duodenum.  Tuberculous  ulceration  has  even  occurred 
in  the  stomach.  At  times  tuberculous  ulcers  develop  primarily  in  the 
colon.  The  development  of  the  tuberculous  ulcer  is  preceded  by  the 
formation  of  a  miliary  tubercle.  It  usually  begins  in  the  solitary  or 
agminated  follicles.  Caseation  and  necrosis  of  the  tubercle  lead  to  ulcera- 
tion. In  Peyer's  patches  only  isolated  folhcles  are  at  first  involved, 
while  in  typhoid  and  intestinal  catarrh  they  are  uniformly  affected.  Ulcera- 
tion at  first  occurs  in  certain  points  of  the  plaque,  but  later  it  becomes 
entirely  involved,  and  the  ulcer,  therefore,  may  be  ovoid.  This  occurs 
in^^the  ileum.  In  the  jejunum  and  colon  they  may  be  round,  but  usually 
lie  transverse  to  the  long  axis.  The  chief  characteristics  of  the  tuberculous 
ulcer  are  as  follows: 

It  is  irregular  in  shape,  more  rarely  ovoid,  and  generally  extends  along 

the  transverse  axis  (girdle  ulcer) ;  the  margin  is  a  light  red  color;  the  edges 

and  base  are  infiltrated  and  often  caseous.     The  submucous  and  muscular 

coat  are  usually  involved,  and  on  the  serosa  are  miliary  tubercles  or  a 

'  Beitrage  zur  Lehre  von  der  Tuberculose,  Marburg,  1882. 


758  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

marked  tubercular  lymphangitis.  The  serosa  is  reddened  and  thick- 
ened, covered  with  layers  of  fibrin,  and  is  often  adherent  to  the  mesentery, 
or  other  loops  of  the  intestines.  As  compared  with  the  great  frequency 
and  number  of  tuberculous  ulcers,  perforation  is,  therefore,  not  frequent. 
There  may  be  stenosis  from  cicatrization  of  the  ulcers  and  this  may  be 
multiple.  They  do  not,  as  a  rule,  show  much  tendency  to  heal.  Swelling 
and  tuberculous  infection  of  the  mesenteric  glands  are  often  present. 

Secondary  infection  of  the  intestines  from  the  peritoneum  may  produce 
tuberculous  ulceration.  The  affection  may  be  primarily  in  the  peri- 
toneum, or  extend  from  the  Fallopian  tubes  or  mesenteric  glands.  The 
intestinal  coils  may  mat  together,  containing  caseous,  suppurating  foci. 

There  may  be  the  peculiar  localized  form  of  tuberculous  tumor  from 
a  chronic  hyperplastic  tuberculosis  occurring  in  the  ileocecal  region,  to 
which  I  have  already  referred.  It  may  simulate  a  new  growth  and  cause 
constriction  of  the  lumen  of  the  bowel. 

There  may  be  a  chronic  hyperplastic  tuberculosis  of  the  intestines  with 
thickening  of  the  gut.  There  is  no  definite  tumor  to  be  felt,  but  the  in- 
duration in  the  right  iliac  fossa,  when  it  occurs  there,  is  similar  to  a  re- 
curring appendicitis.  It  may  attack  other  parts  of  the  intestines. 
Tuberculosis  of  the  rectum  may  occur,  with  fistula  in  ano. 

Tubercle  bacilli  in  the  stools  are  diagnostic  of  these  conditions  when 
found;  otherwise  they  are  difficult  of  diagnosis  unless  by  operation.  The 
symptoms  and  treatment  of  tuberculous  ulcer  (tuberculosis)  of  the 
intestines  will  be  described  at  the  end  of  this  chapter. 

Catarrhal  and  Follicular  Ulcers 

These  types  of  ulcer  occur  in  the  course  of  catarrhal  inflammation  of 
the  intestinal  mucous  membrane,  and  are  described  in  that  chapter. 

Ulcerative  Colitis 

This  special  form  of  ulceration  of  the  colon  was  first  described  by 
Hale  White,  colitis  occurring  especially  in  institutions  and  insane  asylums. 
Probably  the  greater  percentage  of  these  so-called  cases  of  colitis',  such 
as  occur  in  institutions,  are  true  dysentery. 

Vedder  and  Duval,^  while  working  under  Flexner,  found  that  in- 
stitutional outbreaks  were  due  to  Bacillus  dysenterige.  Osier  and  the  late 
J.  P.  Tuttle  differ  in  this  regard  and  classify  it  as  non-dysenteric.  The 
symptoms  and  treatment  are  of  dysentery. 

Stercoral  or  Decubital  Ulcers 

These  ulcers  are  produced  by  the  pressure  of  hardened  and  stagnating 
feces  on  the  mucous  membrane,  resulting  in  necrosis  and  purulent  in- 
flammation. They  develop  particularly  in  the  cecum,  flexure  of  the 
colon  (hepatic  and  splenic),  sigmoid  flexure,  and  the  rectum,  where  stasis 
is  most  apt  to  occur.  Fecal  concretion  in  the  appendix  is  fairly  common 
and  may  produce  ulcer  and  appendicitis.  They  sometimes  develop  in 
chronic  intestinal  stenosis  above  the  seat  of  stricture. 
1  Journal  Exp.   Med.,  Feb.   5,   1902,  vol.  vi. 


SIMPLE   DUODENAL   ULCER  759 

Ulcers  in  Acute  Infectious  Diseases 

Under  this  group  are  the  specific  ulcers  of  typhoid  and  dysentery; 
diphtheritic  ulceration;  ulcers  of  sepsis;  rarely  duodenal  ulceration  in 
erysipelas;  in  varioloid;  ulcer  of  the  duodenum  in  pneumonia,  a  rare  oc- 
currence. In  acute  pemphigus  and  in  pellagra  isolated  cases  have  been 
reported,  also  in  purpura. 

XTlcers  in  Constitutional  Diseases 

In  acute  leukemia,  lymphatic  tumors  may  occur  in  the  intestines, 
especially  in  the  ileum,  and  break  down,  with  the  production  of  ulcers. 
This  is  rare  in  the  chronic  type.     Intestinal 

ulceration  has  occurred  in  scurvy  and  a  few  -,,^ 

isolated  cases  are  reported  in  gout.  / 

Toxic  Ulcers 

• 

Intestinal  ulcers  occur  in  nephritis,  with 
uremic  symptoms  associated  with  the  intes- 
tinal catarrh.  They  lie  chiefly  in  the  large 
intestine.  They  may  occur  in  the  duodenum 
(Fig.  314). 

In  poisoning  with  mercury  they  are  also 
found,  even  when  it  is  not  administered  by 
mouth  or  rectum,  but  by  inunction. 

Changes  in  the  blood  have  been  held 
responsible  for  these  conditions.  With 
nephritis,  the  intestinal  catarrh  is  probably 
a  factor.  It  is  believed  by  many  that  the 
mercury  reaches  the  intestines  by  excretion 
in  the  bile,  and  produces  direct  inflamma- 
tion with  resultant  ulcer,  in  which  decom- 
position or  intestinal  bacteria  play  a  part, 
since  we  find  in  some  cases  a  pseudodiph-  ^j^  3X4._Uremic  ulceration  of 
theritic  membrane.  the  duodenum  (Gaultier). 

Syphilitic,  Gonorrheal  and  Cancerous  Ulcers 

Syphilitic  ulceration  of  the  intestines  is  rather  rare.  In  the  sftiall 
intestine  it  may  be  found  in  a  young  infant  with  inherited  syphilis.  Ulcers 
originate  in  the  lymphatics  or  in  the  mucosa  or  submucosa,  from  a  gumma 
which  gradually  breaks  down.  A  few  cases  of  syphihtic  ulcer  of  the  small 
intestine  in  an  adult  have  been  reported  by  Klebs,  Osier,  and  Birch- 
Hirschfield.  These  ulcers  are  rarely  encountered  in  the  large  intestine, 
except  in  the  rectum  in  its  lowest  part.  Primary  chancre  of  the  rectum 
has  been  observed.  If  feasible,  the  test  for  the  Wassermann  reaction 
should  be  made  to  confirm  the  diagnosis.  The  physical  examination  and 
history  of  the  case  are  important. 


760  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Condylomata  and  gummata  may  break  down,  and  by  cicatrization 
give  rise  to  stricture  of  the  rectum, 

Virchow  notes  that  syphilitic  ulcers  are  of  slight  depth  and  have  a 
smooth  base.     They  are  more  frequent  among  women  than  men. 

Polchen^  found  190  cases  of  stricture  among  women  out  of  219  cases, 
but  believes  that  many  of  these  result  from  ulcerations  caused  by  gonor- 
rheal infection,  from  abscess  of  the  Bartholin  glands,  or  from  fecal 
pressure  (decubital  ulcer),  or  local  traimiatism  from  the  syringe-tip. 

Ulcers  from  gonorrhea,  traumatism,  and  hemorrhoids  occur  in  the 
rectum  and  are  referred  to  under  Proctitis.  Ulceration  of  intestinal 
carcinoma  may  occur,  or  metastatic  nodules  may  break  down  and  ulcerate. 

Intestinal  Myiasis 

A  case  of  fatal  ulceration  of  the  colon  due  to  maggots  has  been 
reported.^ 

General  Symptoms  of  Intestinal  Ulceration 

Our  readers  must  take  into  consideration  the  special  types  of  ulcer, 
their  etiology,  and  the  history  of  the  case  in  making  the  diagnosis. 

In  some  cases  this  is  quite  diflBicult,  as  the  symptoms  are  not  constant. 
The  salient  diagnostic  points  of  intestinal  ulcer  are  as  follows: 

1.  The  appearance  of  pus  in  the  stool.  This  is  frequently  in  small 
quantity  and  in  the  form  of  minute  grayish-white  lumps,  which  appear 
under  the  microscope  as  closely  aggregated  masses  of  pus-cells,  and  are 
especially  important.     At  times  the  pus  is  only  microscopic. 

2.  Necrotic  pieces  of  the  intestinal  mucosa,  such  as  shreds  of  tissue 
from  the  intestinal  wall,  which  must  be  differentiated  from  membranous 
or  shred-like  particles  of  food,  occur  in  some  cases. 

3.  The  appearance  more  or  less  frequently  of  blood  in  the  stool, 
unchanged  and  in  large  amount  as  pure  blood,  or  changed,  coffee-ground, 
or  occult  blood.  In  some  cases  blood  is  only  shown  under  the  microscope, 
or  by  hematin  crystals,  or  by  Weber's  or  the  benzidin  test.  Gastric  ulcer 
and  vicarious  hemorrhage  such  as  from  hemorrhoids,  etc.,  must  be  excluded. 

4.  The  constant  appearance  of  tubercle  bacilli  in  the  stools  in  connec- 
tion with  diarrhea  and  increasing  emaciation  are  diagnostic  of  tuberculous 
ulceration;  also  the  tubercuUn  reaction. 

5.  Persistent  diarrhea  (with  local  tenderness)  and  pain  of  a  greater 
or  lesser  degree  over  a  definite  region  of  the  abdomen,  extending  over  a 
considerable  period  of  time,  associated  with  the  presence  of  pus  and 
blood  in  the  dejecta. 

6.  Tenesmus,  with  pus  and  blood  in  the  stool,  suggests  ulcer,  probably 
in  the  rectum,  and  visual  examination  makes  the  diagnosis. 

The  presence  of  mucus  is  not  diagnostic  of  ulcer. 

Diarrhea. — This  is  present  in  a  large  number  of  cases.  It  is  de- 
pendent on  the  site  of  the  lesions;  ulcerations  of  the  small  intestine,  cecum, 
or  ascending  colon  probably  do  not  produce  diarrhea  unless  there  is  a 

1  Virchow's  Archiv.,  Bd.  127. 

'  Schlessinger,  Wiener  klin.  Wochens.,  January  9,  1901. 


SIMPLE   DUODENAL   ULCER  76 1 

complicating  catarrh,  amyloid  degeneration,  or  some  special  infection 
like  typhoid  fever.  Even  in  the  latter  we  have  constipated  cases.  Ulcers 
of  the  lower  colon  and  rectum  usually  produce  diarrhea,  but  even  here  it 
may  occasionally  be  absent. 

Blood. — Pure  blood  may  be  passed  in  large  amdunts  in  simple  duodenal 
ulcer,  in  ulceration  from  burns,  and  in  typhoid.  Large  hemorrhages 
at  times  occur  from  dysenteric  ulcers.  The  hemorrhages  from  catarrhal 
and  tuberculous  ulcers  are,  as  a  rule,  not  as  large. 

The  blood  may  be  bright  red  or  dark,  or  of  coffee-ground  color,  or 
may  be  only  determined  microscopically  as  blood-corpuscles  orhematin 
crystals,  or  by  tests  for  occult  blood. 

Intestinal  ulcer  may  be  present  without  hemorrhage,  and  other  condi- 
tions may  produce  intestinal  hemorrhage,  such  as  liver  cirrhosis,  etc. 
Repeated  examinations,  however,  will  generally  show  occult  blood. 

Pus  is  diagnostic  of  intestinal  ulcer.  It  is  also  found  in  connection 
with  ulceration  accompanying  neoplasms  of  the  intestines,  and  in  ab- 
scesses which  open  into  the  intestines.  It  is  generally  in  small  amounts. 
Occasionally  no  pus  is  found,  as  in  the  case  of  duodenal  ulcer;  or  the 
ulcer  may  be  single  and  high  up,  so  that  the  pus  will  disappear.  If 
small  grayish- white  specks  are  discovered  in  the  stool,  and  under  micro- 
scopic examination  they  are  found  to  be  pus,  the  diagnosis  of  ulcer  is 
established.     Pus  is  often  only  found  by  the  microscope. 

Mucus  found  mixed  with  the  intestinal  contents  is  the  result  of  asso- 
ciated intestinal  catarrh.  We  can  draw  some  conclusion  from  the  relative 
amount  of  pus,  blood,  and  mucus.     Mucus  is  never  diagnostic  of  ulcer. 

Pure  pus  is  also  found  in  a  diphtheritic  process  of  the  bowel  or  from 
perforating  abscess. 

Blood,  pus,  and  mucus  occur  in  dysentery  and  in  carcinoma  of  the 
lower  colon  or  rectum. 

Shreds  of  Tissue. — They  consist  of  mucous  membrane  and  are 
differentiated  from  particles  derived  from  food;  they  occur  most  fre- 
quently in  dysenteric  ulcer  and  not,  as  a  rule,  in  the  slower  type,  as  in 
tuberculosis;  or  in  the  more  rapid,  as  in  typhoid. 

Tubercle  Bacilli. — Generally  are  diagnostic  of  tuberculous  ulcer, 
in  connection  with  the  other  symptoms.  Rarely  sputum  may  be  swal- 
lowed and  pass  through  without  infection.  Absence  of  bacilli  does  not 
always  prove  absence  of  tuberculous  process.  The  injection  of  tuberculin 
or  the  ocular  test  (conjunctival)  aid  diagnosis  in  the  doubtful  cases. 

Pain. — This  is  occasionally  absent.  If  pain  exists  in  a  circumscribed 
spot  for  a  long  time  and  is  increased  on  pressure,  it  is  probably  due  to 
ulcer.     It  may  at  times  be  caused  by  local  peritonitis. 

Ulcers  of  the  rectum  produce  tenesmus,  which  is  quite  characteristic. 
Rectal  examination  shoidd  always  he  made. 

Fever  is  present  in  the  tuberculous  type,  dysentery,  etc.,  but  not  in 
all  types  of  ulcer,  being  dependent  on  the  etiologic  cause. 

General  Nutrition. — This  may  not  be  disturbed  by  a  few  small  ulcers, 
but  marked  ulceration,  especially  of  the  tuberculous  type,  leads  to  great 
emaciation,  as  the  intestinal  contents  are  rapidly  propelled  and  also 
normal  absorption  is  interfered  with. 


762  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

Perforation  with  general  peritonitis,  local  peritonitis,  or  encapsulated 
abscess  may  occur.     Stricture  may  result  from  ulcers;  also  pancreatitis. 
Prognosis. — The  prognosis  depends  on  the  etiology. 


Treatment 

Hemorrhage  should  be  treated  as  when  from  duodenal  ulcer.  The 
primary  cause  should  receive  appropriate  treatment;  in  uremic  ulcers, 
the  nephritis;  in  sj-philitic  ulcers,  by  hypodermics  of  bichlorid  of  mercury; 
mercurial  inunction;  protiodid,  bichlorid,  and  iodid  of  potassium,  or 
"606"  or  neosalvarsan. 

Heat  or  cold  can  be  applied  for  the  pain  and  rest  in  bed  for  the  severe 
cases. 

In  tuberculous  ulceration,  out-of-door  life  and  change  of  climate 
are  important.  Beechwood  creosote,  2  minims  (0.118)  t.i.d.,  guai- 
acol  carbonate,  carbonate  of  creosote,  and  creosal  (tannosal)  are  useful. 
Average  doses  of  these  remedies  are  10  grains  (0.6)  t.i.d. 

Diet  is  important;  it  should  be  non-irritating  and  chiefly  liquid, 
such  as  milk,  koumiss,  matzoon,  bacillac,  kefir,  fermillac,  lactone-butter- 
milk,  raw  eggs  beaten  in  milk;  soft-boiled  eggs,  broths,  barley  and  rice 
gruel,  chicken  soup,  mushes,  etc.  Fats,  such  as  butter,  emulsion  of  mixed 
fats  (Russell's),  cream,  etc.,  are  of  value. 

Some  cases  can  take  sweetbread,  scraped  beef,  calves'  brains,  cocoa, 
tea  or  weak  coffee,  milk  toast,  rice,  mashed  or  baked  or  boiled  potato,  etc. 

Somatose  and  malt-tropon  can  be  given  in  broths  or  soups. 

Compound  tincture  of  catechu,  chalk  mixture,  opium,  etc.,  are  useful 
for  severe  diarrhea.     The  following  are  excellent: 

R.  Camph.  tinct.  opii  \  - ,  «      /  ^r    \ 

Bismuthsubnit       / aa  5ss  (16.0); 

Mist,  cretae 5  ij  (60.0) ; 

Aq.  destil q.  s.  ^iv  (125.0). — M. 

Sig. — Shake.     Dose,  5ij  (8.0),  every  three  hours. 

I^.  Tr.  opii mx  (0.59); 

Mist,  cretae 3  j  (4-o) ; 

Comp.  tinct.  catechu q.  s.  3ij  (8.0). — M. 

Sig. — Dose,  oij  (8.0).     Administer  every  three  hours. 

Bismuth  subnitrate,  15  to  30  grains  (1.0-2.0),  three  or  four  times 
a  day,  or  bismuth  subcarbonate  or  bismuth  saHcylate,  10  to  15  grains 
(o.ty-i.o),  may  be  substituted.     Avoid  opiates  as  much  as  possible. 

Tannigen,  bismuth,  subgallate,  tannalbin,  and  tannocol  are  useful 
in  average  doses  of  10  to  15  grains  (0.6-1.3)  three  or  four  times  a  day. 

High  injections  of  silver  nitrate,  1:3000;  thymol,  i  :2ooo;  salicylic 
acid,  I  :  500;  boric  acid,  i  :  500;  tannic  acid,  i  :  1000;  and  protargol  or 
argyrol,  i  :  1000,  are  of  service  in  rectal  and  colonic  ulcers. 

Carbolic  acid  should  not  be  used,  and  bichlorid  of  mercury  (i  :  10,000) 
by  recurrent  irrigation  only  in  typhoid  in  the  diphtheritic  form  of  colitis. 
Special  local  treatment  is  necessary  for  proctitis,  as  already  described. 


DISEASES    OF   THE   BLOOD-VESSELS  763 

DISEASES  OF  THE  BLOOD-VESSELS ;  EMBOLISM  AND  THROMBOSIS  OF  THE 
MESENTERIC  ARTERIES  AND  VEINS  (INFARCTION  OF  THE  BOWEL) 

Embolism  and  thrombosis  of  the  mesenteric  arteries  are  comparatively 
rare  affections. 

When  the  mesenteric  vessels  are  blocked  by  emboli  or  thrombi, 
infarction  follows  in  the  territory  supplied  by  the  vessel,  which  may 
continue  on  to  gangrene  or  perforation  and  peritonitis.  If  only  a  few 
small  vessels  are  occluded  there  may  be  few  if  any  symptoms,  and  the 
circulation  may  be  re-established.  Welch^  states  that  about  70  cases  of 
embolism  or  thrombosis  of  the  mesenteric  arteries  have  been  published, 
while  Gallavardin^  has  collected  83  cases,  of  which  63  were  of  embolism. 

As  the  clinical  symptoms  of  obstruction  of  the  mesenteric  arteries 
and  veins  can  scarcely  be  differentiated  during  life,  the  symptoms  being 
much  the  same,  and  since  careful  study  of  their  etiology  may  aid  in 
diagnosis,  it  is  advisable  to  describe  them  together.  Including  both 
arterial  and  venous  mesenteric  obstruction,  Jackson,  Porter,  and  Quimby 
have  studied  about  30  cases  in  Boston,  and  have  collected  214  cases  in  all. 

Etiology. — Embolism  and  Thrombosis  of  the  Mesenteric  Arteries. — 
In  a  majority  of  cases  occlusion  is  due  to  embolism  and  rarely  to  thrombosis. 

The  chief  source  of  the  emboli  are  traceable  to  endocarditis  (valvular 
lesions)  or  atheroma  of  the  aorta,  or  rarely  from  a  pulmonary  thrombosis 
or  aneurysm  of  the  aorta. 

Thrombosis. — Local  changes  in  the  vessels,  as  endarteritis  (described 
by  Litten),  syphilitic  endarteritis,  injury  and  pressure  from  calcareous 
glands,  have  been  given  as  causes.  RoUeston  refers  to  periarteritis 
nodosa,  a  rare  condition  in  man,  with  the  production  of  multiple  aneurysms 
which  produces  pain,  colic,  and  diarrhea  with  ulceration.  The  superior 
mesenteric  artery  is  more  often  affected.  Verminous  aneurysms  cause 
infarctions  in  the  horse. 

Etiology  of  Thrombosis  of  the  Mesenteric  Veins  or  the  Portal  Vein. — 
Welch^  has  collected  32  cases,  and  has  demonstrated  that  the  superior 
mesenteric  vein  is  more  often  affected  than  the  inferior  mesenteric. 
Among  the  causes  are  pressure  on  the  portal  vein,  as  in  cirrhosis  or  cancer 
of  the  liver;  neoplasms  of  the  abdomen;  chronic  peritonitis,  with  forma- 
tion of  constricting  tissue;  local  pressure  or  incarceration  of  the  intestines; 
suppurative  inflammation  of  the  portal  system  as  a  result  of  infection,  as 
in  appendicitis,  intestinal  ulcer,  or  dysentery.  Traumatism  may  produce 
inflammation  and  thrombosis.  Mayland^  shows  that  it  may  occur  after 
operation;  from  tuberculous  peritonitis  or  diseased  mesenteric  glands. 
Hemorrhagic  infarction  of  the  intestines,  as  a  rule,  occurs  with  venous 
thrombosis,  and  the  general  symptoms  are  the  same  as  due  to  arterial 
occlusion;  hence,  the  comparative  study  of  the  etiology  of  these  differ- 
ent conditions  is  important  for  diagnosis. 

We  would  note  that  in  a  few  rare  instances  Welch  and  Rolleston 
have   reported   exceptional   conditions;   the  former,    that   acute  portal 

^  AUbutt's  System  of  Medicine,  1894,  vol.  ii;  also  vol.  iv. 
^  Gaz.  des  H6p.,  Paris,  1901,  p.  929. 
'  AUbutt's  System  of  Med.,  vol.  v. 
*  Brit.  Med.  Jour.,  1901,  vol.  ii. 


764  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

obstruction  has  caused  hemorrhagic  infarction  of  the  intestines,  without 
thrombosis  of  the  mesenteric  vein;  and  the  latter,  thrombosis  of  both 
veins  without  infarction,^ 

Elliot,  Sprengel,  and  Berg  have  described  cases,  and  H.  Fisher^  reports 
two  cases  that  are  of  interest. 

Pathology  of  Occlusion  to  the  Superior  Mesenteric  Artery. — The 
changes  resulting  from  occlusion  of  this  vessel  or  its  branches  are  hemor- 
rhagic infarcts  and  peritonitis.  If  only  small  branches  are  occluded,  the 
results  are  embolic  or  thrombotic  ulcers  of  the  intestines,  to  which  article 
I  refer  my  readers. 

The  transverse  duodenum,  ileum,  jejunum,  caput  coli,  ascending 
and  transverse  colon  are  suppHed  by  this  vessel  and  lesions  of  the  intestines 
occur  in  that  portion  of  the  bowel  supplied  by  the  occluded  branch  or 
branches.  It  usually  involves  a  continuous  segment  of  the  gut,  quite 
frequently  in  the  lower  jejunum  and  ileum;  but  if  smaller  vessels  or 
branches  are  occluded,  there  may  be  lesions  scattered  in  several  places 
over  the  bowel,  with  healthy  segments  between  them. 

The  superior  mesenteric  artery  has  such  long  and  small  branches 
that  it  acts  functionally,  like  a  terminal  artery,  so  sufficient  blood  cannot 
be  supplied  to  the  intestines  if  it  or  one  of  its  branches  be  occluded. 

Welch  and  Mall^  have  demonstrated  experimentally  that  if  a  branch 
be  occluded,  the  blood  which  produces  the  hemorrhagic  infarction  is 
derived  from  anastomosing  arteries  and  not  from  regurgitation  from  the 
portal  vessels,  as  was  formerly  supposed. 

The  following  are  the  clinical  appearances  in  the  intestines:  Arteries, 
empty,  except  at  obstruction.  There  are  venous  hyperemia;  edema 
and  necrosis;  hemorrhages  in  the  mucous  membrane  and  mesentery. 
The  mucosa  is  a  dark  red  and  finally  becomes  necrotic,  of  a  brownish- 
green  appearance.  The  intestinal  canal  contains  extravasated  blood, 
either  fresh  or  tarry  looking.     Necrosis  of  the  intestines  is  present. 

The  serous  coat  is  inflamed,  not  only  in  the  affected  area  but  also 
over  the  healthy  intestines,  and  the  coils  may  become  adherent  and  be 
covered  with  fibrin.  There  may  be  a  blood-stained  or  purulent  exudate 
in  the  peritoneal  cavity.  Occasionally  gas  may  be  present  in  the  cavity, 
due  to  the  Bacillus  aerogenes  capsulatus  or  to  emphysema  of  the  mucosa. 

Clinical  Sjmiptoms. — Kussmaul  and  Gerhardt^  first  clearly  described 
these  some  years  ago. 

There  are  two  types,  the  most  frequent  characterized  by  hemor- 
rhage from  the  intestines;  the  second,  simulating  intestinal  obstruction, 
with  or  without  peritonitis. 

Usually  the  onset  is  sudden,  frequently  with  violent,  colicky  pains  in 
the  region  of  the  umbilicus,  which  may  gradually  become  diffuse,  and 
at  the  same  time,  there  is  tenderness  on  pressure  over  the  abdomen.  We 
must  remember  that  in  some  cases  there  is  an  absence  of  pain. 

Vomiting  may  accompany  the  pain.  In  some  cases  there  may  be 
blood  in  the  vomitus.     Diarrhea  may  begin  shortly  after  the  pain  and 

^  RoUeston,  Trans.  Path.  Soc,  vol.  xlii. 

2  Archiv  of  Diag.,  N.  Y.,  Oct.,  1909. 

^  Johns  Hopkins  Hosp.  Reports,  vol.  i. 

*  Wiirzburger  med.  Zeitschr.,  1863  and  1864,  Bd.    iv.  and  v. 


DISEASES    OF   THE    STOMACH    AND    INTESTINES  765 

Intestinal  ulceration  occurring  with  multiple  degenerative  neuritis 
probably  belongs  to  the  class  of  thrombotic  ulcers,  there  being  degenera- 
tive changes  (arteritis)  influenced  by  the  neuritis  (trophic).  Fracture  of 
the  spine  has  resulted  in  intestinal  ulceration. 

Amyloid  Ulcers 

This  t3^e  of  intestinal  ulcer  is  rare,  and  would  only  be  suspected 
when  associated  with  amyloid  degeneration  of  other  organs,  such  as  of 
the  liver,  spleen,  in  cases  suffering  from  long-continued  suppuration, 
cachexia,  tuberculosis,  syphilis,  rickets,  or  leukemia.  There  would  be 
diarrhea,  symptoms  of  ulcer,  and  deficient  absorption  from  the  intestines. 
Amyloid  ulcers  may  be  found  in  any  part  of  the  intestinal  tract,  though 
more  usually  in  the  small  intestine.  They  are  generally  multiple  and  may 
involve  large  areas.  They  are  from  the  size  of  a  pea  to  large  girdle  ulcers, 
nearly  circumscribing  the  bowel. 

Leube  believes  the  ulcers  originate  from  circulatory  disturbances  due 
to  amyloid  degeneration  of  the  walls  of  the  small  arteries.  The  vessels 
of  the  mucous  membrane  are  first  affected,  but  the  process  may  involve 
the  entire  coat  of  the  bowel.  The  ulcers  have  no  tendency  to  heal. 
Other  areas  of  intestines  between  the  ulcers  may  be  in  a  condition  of 
amyloid  degeneration.  The  mucous  membrane  is  pale  and  waxy  in 
appearance  and  some  of  the  villi  are  missing. 

On  postmortem  a  weak  solution  of  iodin  gives  a  mahogany-brown 
color,  the  test  for  amyloid  degeneration.  The  addition  of  sulphuric  acid 
turns  it  violet  or  blue. 

Tubercular  Ulcers  and  Intestinal  Tuberculosis 

Tuberculosis  is  a  quite  frequent  cause  of  ulceration  of  the  intestines. 
The  infection  may  be:  (i)  Primary  in  the  intestinal  mucous  membrane; 
(2)  most  commonly  secondary  to  diseases  of  the  lungs;  and,  rarely,  (3) 
secondary  to  tubercular  peritonitis. 

Primary  intestinal  tuberculosis  occurs  most  frequently  in  children,  and 
with  it  may  be  associated  tuberculosis  of  the  mesenteric  glands  or 
tubercular  peritonitis. 

R.  Koch  believes  that  bovine  tuberculosis  differs  from  human  tubercu- 
losis, and  that  infection  from  diseased  milk  or  milk  of  tuberculous  cattle 
hardly  ever  occurs,  and  it  is  unnecessary  to  take  any  precautions.  Von 
Behring  takes  the  opposite  view. 

In  the  Charite  Hospital  in  Berlin  there  were  only  10  cases  in  ten 
years.  In  3104  cases  of  tuberculosis  in  children,  there  were  16  of  primary 
infection.  There  have  been  investigations  recently  reported  which  are 
suggestive  that  infection  through  the  intestines  is  more  common  than 
we  suppose;  notably,  Macfayden  found  tubercle  bacilli  in  the  mesenteric 
glands  of  5  out  of  20  children  postmortem,  wdth  no  tubercular  lesions 
elsewhere;  and  Ravenel  in  8  cases  out  of  25. 

Recent  consensus  of  opinion  holds  that  primary  intestinal  infection 
occurs  through  tuberculous  milk.     Milk  from  an  infected  nurse  or  mother 


766  DISEASES    OF   THE   STOMACH   AND    INTESTINES 

Thrombosis  of  the  Mesenteric  Veins  or  Portal  Vein. — This  condition 
is  extremely  serious. 

Anatomic  Findings. — The  arteries  are  distended  (thus  differing  from 
the  superior  mesenteric  artery  obstruction);  thrombotic  processes  are 
found  in  the  mesenteric  vein  or  its  branches  or  in  the  portal  vein.  The 
intestines  show  similar  conditions  to  obstruction  of  the  arteries — infarc-^ 
tion,  necrosis,  hemorrhage,  peritonitis,  etc. 

Symptoms. — The  clinical  picture  may  present  the  same  type  as 
in  obstruction  of  the  mesenteric  arteries — colicky  pains,  tenderness, 
blood,  diarrheal  movements,  etc.  Rarely  there  may  be  hematemesis, 
and  occasionally  constipation.  The  etiology,  such  as  appendicitis, 
diseases  of  the  liver  causing  pressure  on  the  portal  vein,  abdominal 
neoplasms  or  constricting  bands,  producing  pressure,  etc.,  and  the  ex- 
clusion of  the  causes  of  embolism,  may  aid  our  diagnosis. 

Treatment. — Temporarily  employ  an  ice-bag  to  the  abdomen;  stimu- 
lants, such  as  strychnin  or  camphor  oil,  by  hypodermic;  morphin,  }4  grain 
(0.016),  and  ernutin,  5  minims  (0.296),  by  hypodermic;  gelatin  solution, 
calcium  chlorid,  or  lactate  of  calcium  to  check  hemorrhage,  as  described 
in  Dysentery. 

Immediate  resort  to  laparotomy  and  resection  of  the  diseased  area 
is  indicated,  if  possible.  Cases  of  recovery  after  this  procedure  have 
been  reported.  Elliott  resected  48  inches  of  intestines  in  one  case  with 
recovery.     Proctoclysis  is  of  value  for  the  sepsis. 


CHAPTER  XXIX 
NEOPLASMS  OF  THE  INTESTINES 

MALIGNANT  GROWTHS 
(Synonym. — Neoplasmata  Maligna  Intestini) 

Though  many  have  claimed  that  intestinal  cancer  is  a  comparatively- 
rare  disease,  recent  statistics  show  that  it  has  increased  in  frequency, 
and  is  more  common  than  has  been  generally  supposed. 

Among  the  malignant  tumors  met  with  in  the  intestines,  carcinoma 
is  by  far  the  commonest.  Sarcoma  and  lymphosarcoma  are  also  found 
and  will  be  described  in  a  separate  section. 

CARCINOMA  OF  THE  INTESTINES 

Etiology. — The  cause  of  intestinal  cancer,  like  that  of  cancer  of 
other  organs,  is  still  unknown.  There  have  been  many  theories  ad- 
vanced, such  as  the  embryonal  origin,  parasitic  infection,  the  theory  of 
irritation,  etc.  The  traumatic  theory  (irritation  as  the  cause),  in  so  far 
that  it  might  hasten  the  development  of  the  condition,  is  afiforded  a  certain 
amount  of  plausible  support,  in  view  of  the  fact  that  the  disease  occurs 
most  frequently  in  those  parts  of  the  bowels  in  which  the  feces  are  retarded, 
and  hence  act  as  a  source  of  irritation.  The  points  of  selection  for  the 
development  of  cancer  are  the  same  as  those  in  which  the  so-called  decubi- 
tal or  stercoral  ulcers  most  frequently  develop,  and  we  may  assume 
they  probably  originate  from  the  cicatricial  tissue  of  these  ulcers,  in  some 
cases  at  least,  or  on  the  base  of  other  ulcers. 

Billroth  has  found  a  carcinoma  in  the  scar  of  a  dysenteric  stricture,' 
just  as  it  occurs  in  the  case  of  carcinoma  engrafted  on  the  scar  of  a  stomach 
ulcer.  It  will  probably  eventually  be  shown  to  be  due  to  some  specific 
organism  in  my  opinion. 

Sex. — Carcinoma  of  the  intestines  appears  to  be  somewhat  more 
common  in  men  than  in  women. 

Age. — In  general  this  lesion  is  most  common  between  the  fortieth 
and  sixty-fifth  year. 

Contrary  to  cancer  developed  in  other  regions,  cancer  of  the  in- 
testines has  been  encountered  quite  frequently  before  the  fortieth  year. 
It  has  been  found  even  in  children;  several  cases  being  reported  at  the 
ages  of  eleven  to  seventeen,  and  two  cases  in  children  of  three  years  of 
age. 

Maydl,  of  Vienna,  has  calculated  from  records  that  one-sixth  of  all 
cases  of  intestinal  carcinoma  occur  between  thirty  and  forty  years,  and 
one-seventh  before  the  thirtieth  year.  It  is  important  to  remember  that 
early  occurrence  is  fairly  frequent. 

767 


768  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

Situation  of  the  Carcinoma. — Cancer  of  the  bowel  is  rare  in  the 
small  intestine,  occurs  quite  frequently  in  the  colon,  and  most  commonly 
in  the  rectum. 

From  1882-93,  from  autopsies  in  the  Vienna  General  Hospital,  Riegel 
states  5  cases  were  in  the  duodenum;  6  in  the  ileum;  none  in  the 
jejunum;  i  in  the  vermiform  appendix;  14  in  the  cecum;  63  in  the  colon; 
40  in  the  sigmoid,  and  114  rectal  cancers. 

At  the  same  hospital,  during  twelve  years,  out  of  254  cases  of  cancer 
of  the  intestines,  Maydl  found  in  the  living  that  224  were  cancer  of  the 
rectum. 

Bryant,  in  no  autopsies,  found  carcinoma  of  the  small  intestine  6 
times;  7  times  in  the  cecum  and  ileocecal  region;  19  times  in  the  transverse 
colon,  including  its  flexures;  78  times  in  the  sigmoid  flexure  and  rectum. 

Leichtenstern's  data  show  that  80  per  cent,  of  all  intestinal  cancers 
occur  in  the  rectum. 

Other  statistics  are  given.  They  all  show  the  preponderance  of  rectal 
cancer. 

Intestinal  cancers  are  almost  always  primary,  and  secondary  growth 
by  metastasis  is  extremely  rare. 

It  may  occur  through  direct  extension  by  continuity,  as  a  cancer  of 
the  pancreas  may  extend  to  the  intestines. 

Primary  carcinomata  of  the  intestines  often  give  rise  to  metastases  in 
other  organs.  These  are  most  frequently  found  in  the  lymph-glands, 
especially  in  the  neighborhood  of  the  neoplasm. 

Secondary  metastases  in  the  liver  are  quite  frequent,  no  matter  where 
the  situation  of  the  carcinoma.  The  peritoneum,  omentum,  mesentery, 
and  lungs  may  be  involved,  and  occasionally  the  kidneys. 

Hauser  calls  attention  to  certain  peculiarities  regarding  the  metastases 
in  different  forms  of  carcinoma  of  the  large  intestine.  Colloid  carcinoma 
chiefly  involves  the  serous  coat  and  metastases  of  internal  organs  are 
rare.  Medullary  tumors  involve  adjacent  lymph-glands,  while  simple 
and  scirrhous  carcinomata,  even  when  small,  frequently  cause  carcinoma 
of  the  liver. 

Morbid  Anatomy. — Several  varieties  of  carcinoma  are  found  in  the 
intestines,  most  often  the  cylindric  epithelial-celled  carcinoma  (adeno- 
carcinoma), starting  in  the  cylindric  epithelium  of  the  intestinal  glands 
(follicles  of  Lieberkiihn).  It  occurs  most  frequently  in  the  large  intestine, 
as  do  medullary  carcinoma  and  colloid  cancer.  More  rarely  the  scirrhous 
carcinoma  is  found.  The  epitheliomatous  chancroid  occurs  in  the  lower 
rectum  at  the  anus,  and  it  may  involve  the  perineum  and  vagina. 

In  the  small  intestine  the  primary  proliferation  starts  from  the  glands 
of  Brunner;  in  cases  developing  from  cicatrices,  proliferation  may  start 
from  glandular  tubules  which  have  grown  deep  down  into  the  tissue. 
The  growth  varies  in  consistency,  depending  upon  whether  connective 
tissue  or  cells  predominate;  if  the  former,  then  the  tumor  presents  a  hard 
consistence  (scirrhous) ;  and  if  the  latter,  then  it  is  less  firm  and  occasion- 
ally soft  and  succulent.  The  colloid  cancer  contains  a  brown  viscid  fluid. 
The  scirrhous  shows  a  tendency  to  ulcerate. 

The  cancer  may  form  a  hard  annular  induration,  as  in  the  colon, 


NEOPLASMS    OF    THE   INTESTINES  769 

or  a  circumscribed  nodule  or  an  ulcerating  gangrenous,  cauliflower  growth 
as  in  the  rectum.     The  nodule  may  develop  into  a  single  large  tumor 
or  several  smaller  masses;  the  softer  tumors  usually  grow  to  larger  size. 
At  other  times  the  mass  may  protrude  into  the  intestines,  like  a  polypus;  or 
may  infiltrate  a  large  surface  of  the  bowel,  so  that  it  becomes  stiff  and  rigid. 

In  the  majority  of  intestinal  carcinomata  the  surface  is  ulcerating. 

The  annular  form  of  the  growth  is  most  common,  tending  to  involve 
the  circumference  of  the  bowel.  It  may  develop  from  a  small  nodule  or, 
more  frequently,  on  the  base  of  an  old  annular  cicatrix,  due  to  former 
ulceration. 

Stenosis  of  the  canal  is  often  the  residt;  colloid  cancer,  however,  rarely 
produces  it. 

Secondary  changes  develop;  the  intestines  become  dilated  through 
stagnating  feces  and  gas,  and  the  walls  hypertrophied  above  the  point 
of  stenosis  through  overexertion  to  overcome  the  obstacle.  Catarrhal 
inflammation  and  stercoral  ulcers  develop  in  the  dilated  portion  of  the 
gut  and  perforation  may  ultimately  occur. 

Below  the  stricture  the  intestinal  walls  are  thinner,  and  if  the  stenosis 
is  narrow,  the  intestines  may  be  empty  and  contracted. 

Stenosis  of  the  bowel  may  be  produced  by  a  growth  of  the  cancer 
into  its  lumen  or  by  infiltration  of  the  entire  wall. 

Large  masses  of  very  hard  scybalse  often  accumulate  above  the 
seat  of  obstruction  and  are  difficult  to  distinguish  from  the  carcinoma 
proper,  so  that  on  autopsy  a  small  growth  may  be  found  which  intra 
vitam  was  believed  to  be  of  large  size. 

When  stenosis  of  the  bowel  occurs,  all  the  symptoms  are  present 
which  are  described  under  this  condition. 

Narrowing  of  the  bowel  does  not  always  take  place.  Sometimes 
the  symptoms  of  stenosis  may  gradually  disappear,  being  due  to  ulcera- 
tion of  the  neoplasm,  so  that  the  canal  again  becomes  patent.  As  a  rule, 
the  tumor  tends  to  grow  and  fill  it  up  again. 

The  necrotic  process  often  causes  more  oi*  less  hemorrhage,  and 
in  rare  cases,  if  a  large  vessel  is  eroded,  there  may  be  a  fatal  issue.  The 
canal  may  become  patent  by  a  direct  connection  becoming  established, 
through  ulceration  and  adhesions,  between  two  loops  of  the  intestines. 

The  muscular  and  serous  coats  are  frequently  involved,  and  peritoneal 
adhesions  develop  which  may  unite  the  diseased  intestines  to  other 
portions  of  the  intestines,  or  to  some  adjacent  organ,  which  may  con- 
stitute a  serious  obstacle  to  the  removal  of  the  growth.  Perforation 
may  rarely  occur  before  the  formation  of  adhesions,  with  resulting  general 
peritonitis,  or  there  may  be  a  circumscribed  abscess  formed  within  the 
adhesions.  Marked  displacement  of  the  intestines  may  be  caused  by  the 
formation  of  these  adhesions. 

A  carcinomatous  peritonitis  may  be  produced  by  extension  from  the 
serous  layer  of  the  intestines,  accompanied  by  hemorrhagic  exudation. 
Perforation  into  other  organs  which  have  become  agglutinated  to  the 
bowel  can  occur;  thus  a  fistulous  opening  forms  between  the  colon  and  the 
stomach  or  bladder,  or  vagina  or  uterus,  or  between  the  large  and  small 
intestines,  or  from  the  bowel  through  the  abdominal  wall. 
49 


770  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

The  omentum  and  mesentery  may  become  infiltrated  with  cancerous 
masses.  A  band  may  be  formed  by  the  stiffened  omentum,  which  may 
cause  a  knuckhng  or  a  twisted  bowel.  The  mesentery  may  kink  and  twist 
the  intestines. 

S3miptoms. — The  symptoms  vary,  depending  on  the  position  of  the 
neoplasm,  the  rapidity  of  its  growth,  and  the  character  of  the  cancer. 
There  may  be  symptoms  at  first  of  habitual  constipation  or  of  hemorrhoids, 
or  of  stenosis  of  the  intestines,  or  of  peritonitis,  or  icterus,  or  of  cachexia  of 
uncertain  origin.  It  seems  preferable  to  first  review  the  general  and  then 
the  local  symptoms,  depending  upon  the  position  of  the  tumor,  as  occurring 
with — 

1.  Carcinoma  of  the  duodenum. 

2.  Carcinoma  of  the  small  intestine  (jejunum  and  ileum). 

3.  Carcinoma  of  the  colon  (cecum  to  sigmoid  flexure). 

4.  Carcinoma  of  the  rectum. 

General  Symptoms. — ^There  are  symptoms  common  to  all  cases  of 
carcinoma,  of  which  anemia  and  cachexia  are  the  most  important.  As 
a  rule  they  occur  together,  though  one  may  develop  before  the  other. 
In  many  patients  weakness,  pallor,  and  emaciation  are  the  first  signs 
noticed,  and  arouse  the  suspicion  of  a  serious  disease.  There  may  be 
only  slight  local  symptoms,  moderate  constipation,  and  a  sense  of  weight 
or  discomfort  in  the  abdomen,  with  loss  of  appetite,  coated  tongue,  and 
slight  dyspeptic  disturbances.  There  are  loss  of  weight  and  a  peculiar 
cachectic  appearance.  On  the  other  hand,  the  local  symptoms  may  be 
the  more  pronounced,  or  the  local  and  general  symptoms  may  occur 
together. 

Quite  frequently,  especially  in  those  cases  of  carcinoma  which  run  a 
rapid  course,  fever  is  present.  I  have  seen  a  number  of  cases  in  which  it 
is  entirely  absent.  It  probably  depends  upon  an  ulcerative  condition  in 
the  growth  and  absorption  of  toxic  products.  The  tumor  may  cause 
s)anptoms  in  adjacent  organs  by  dragging  upon  them  or  constricting  them. 
There  may  be  radiating  pains  from  compression  of  nerves  and  also  dis- 
turbances of  the  circulation,  such  as  edema  of  the  lower  extremities. 

Symptoms  of  chronic  intestinal  obstruction  are  frequently  present, 
but  not  in  all  cases.  The  symptoms  may  develop  gradually,  the  constipa- 
tion increasing,  or  there  may  be  a  sudden  stoppage,  with  all  the  signs  of 
acute  obstruction.  The  clinical  symptoms  of  cancerous  obstruction  are 
similar  to  those  from  stenosis  of  the  intestines  caused  by  other  processes, 
and  are  described  in  the  chapter  on  that  subject. 

When  acute  obstruction  suddenly  occurs  during  the  course  of.  chronic 
stenosis  a  fatal  result  may  ensue  within  a  few  days.  Fecal  retention  has 
been  reported  in  connection  with  malignant  stenosis,  lasting  even  over 
eighty  days,^  without  the  presence  of  fecal  vomiting. 

Diarrhea  is  fairly  frequent  in  carcinoma  of  the  intestines.  It  is  of 
assistance  in  clearing  up  the  commencing  obstruction,  and  in  some  cases 
alternates  with  constipation. 

In  some  patients  the  stools  appear  as  small  hard  balls,  cylindric,  like 
a  pencil,  or  flat  and  tape-like,  as  if  they  had  passed  a  strictured  point. 
*  Copper- Foster,   Med.  Times  and   Gazette,  Sept.,    1867. 


NEOPLASMS    OF   THE    INTESTINES  77 1 

These  are  not  always  characteristic,  as  they  may  appear  with  nervous 
conditions. 

The  stools  frequently  contain  pus,  blood,  and  mucus.  The  pus  may 
be  microscopic  and  the  blood  occult.  The  appearance  of  the  first  two 
(pus  and  blood)  is  significant.  If  the  growth  is  ulcerating  markedly,  the 
stool  has  a  most  offensive  odor.  In  this  event  particles  of  tumor  may 
rarely  be  found  in  the  dejecta,  which  show  under  the  microscope  the  nature 
of  the  growth.  They  may  be  of  fair  size  or  very  small,  so  that  careful 
examination  of  the  fecal  matter  may  be  necessary  in  order  to  find  them. 
Irrigation  of  the  bowel  is  of  assistance  if  the  neoplasm  is  situated  in  the 
large  intestine. 

One  of  the  most  important  factors  in  our  diagnosis  is  the  detection  of 
the  physical  signs  of  a  tumor. 

The  growth  is  from  the  size  of  a  walnut  to  that  of  a  child's  head.  It 
is  often  easily  palpable,  hard,  and  usually  has  an  uneven  nodular  surface. 

A  marked  peculiarity  of  this  type  of  tumor  is  its  great  mobility  under 
the  palpating  hand  of  the  examining  physician.  Even  in  the  cecum  and 
ascending  and  descending  colon  the  tumor  is  distinctly  movable  as  a  rule. 
The  mass  is  usually  situated  in  the  lower  half  of  the  abdomen,  most  fre- 
quently in  the  lower  left  iliac  region,  as,  unless  there  are  marked  adhesions, 
the  intestines  are  dragged  down  there  by  their  own  weight.  If  the  growth 
is  in  the  cecum,  the  right  iliac  region  is  involved. 

I  have  already  referred  to  the  fact  that  on  autopsy  the  tumor  is 
frequently  found  to  be  smaller  than  it  was  apparent  to  palpation,  this 
being  due  to  the  thickening  of  the  gut  above  the  stenosis  and  to  the  fecal 
accumulation. 

Abdominal  pain  is  present,  which  will  be  described  under  Local  Symp- 
toms, and  the  tumor  is  at  times  tender. 

In  some  cases  simple  abdominal  palpation  is  not  sufficient,  and  it  may 
be  necessary  to  examine  the  patient  under  an  anesthetic.  In  every  case 
digital  examination  of  the  rectum  and,  if  necessary,  the  passing  of  a  rectal 
bougie  or  introduction  of  a  speculum  should  be  employed.  In  women  a 
vaginal  examination  should  be  also  made.  I  strongly  deprecate  the  inser- 
tion of  the  entire  hand  into  the  rectum  under  anesthesia,  as  has  been  some- 
times advised.  The-.r  rays  are  of  great  value  as  an  aid  to  diagnosis,  the 
rontgenograph  showing  the  point  of  stenosis  caused  by  the  growth. 

When  the  cancer  is  fully  developed  we  may  have  peritonitis,  either 
local  or  general,  as  a  complication.  If  the  peritonitis  is  of  a  cancerous 
nature,  a  hemorrhagic  exudation  and  the  presence  of  nodules  under  the 
abdominal  wall  will  indicate  this  fact.  Acute  perforative  peritonitis  will  be 
indicated  by  the  usual  symptoms  of  this  condition.  On  the  other  hand,  we 
may  have  circumscribed  adhesions  with  the  presence  of  local  fecal  abscess. 

Perforation  may  occur  into  adjacent  adherent  organs  which  will  present 
special  symptoms. 

Among  the  chief  communications  are: 

I.  Communication  between  the  colon  and  stomach.  There  may  be  a 
valvular  communication  or  it  may  be  free.  If  the  direction  of  the  passage 
is  from  the  stomach  into  the  colon,  symptoms  of  lientery  develop — un- 
digested food,  such  as  rice,  potatoes,  meat,  etc.,  appear  rapidly  in  the  stools. 


772  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Diarrhea  occurs  shortly  after  the  ingestion  of  food  with  evacuation  of 
sohd  contents.  If  the  valvular  action  is  in  the  opposite  direction,  feculent 
vomiting  takes  place.  If  the  fistulous  opening  is  perfectly  free,  then 
lientery  and  fecal  vomiting  occur  together  or  may  alternate.  This  com- 
bination of  symptoms  is  pathognomonic.  Lavage,  especially  if  the  fluid 
be  colored  with  methylene-blue  or  carmin,  3  grains  (0.194),  will  demon- 
strate that  the  liquid  rapidly  escapes  from  the  stomach,  and  is  expelled 
from  the  bowel  without  being  decolorized  or  discolored. 

If  the  rectum  is  inflated  with  air  or  CO2  the  stomach  will  be  distended 
with  gas,  or  after  injection  of  i  to  2  liters  (quarts)  of  colored  fluid  into  the 
bowel  some  can  be  secured  from  the  stomach  by  aspiration. 

2.  Communication  between  the  rectum  and  bladder.  Fecal  matter 
and  gas  escape  into  the  bladder  and  are  voided  through  the  urethra. 
Severe  septic  cystitis  results,  or  the  urine  may  escape  from  the  bladder 
and  be  discharged  through  the  stools.  A  carmine  solution  injected  into 
the  rectum  or  bladder  will  demonstrate  the  condition,  and  will  appear 
respectively  in  the  urine  or  feces. 

3.  Communication  between  the  rectum,  uterus,  and  vagina  are  also 
met  with,  and  give  rise  to  the  passage  of  fecal  matter  through  these  organs, 
and  also  to  severe  inflammation.  Injection  of  weak  carmin  solution  or 
methylene-blue  into  the  rectum  will  demonstrate  the  communication. 

4.  Communication  between  the  bowel  and  abdominal  wall.  There 
may  be  a  feculent  or  fetid  discharge,  or  even  of  particles  of  fecal  matter, 
if  the  communication  is  with  the  lower  small  or  large  intestines.  If  the 
communication  is  high  up,  it  may  be  chylous  or  biliary.  This  condition 
appears  usually  in  the  last  stage  of  the  disease.  Injection  of  carmin  red 
solution  through  the  fistula  will  appear  in  the  stool.  Ulcerative  processes 
(tubercular)  may  produce  similar  communication. 

The  urine  is  not  characteristic,  shows  indican,  occasionally  acetone 
and  diacetic  acid.  Albumin  is  present,  frequently  casts.  Secondary 
anemia  occurs.     Leukocytosis  is  moderate  and  eosinophiles  are  increased. 

Symptoms  Due  to  Position  of  the  Cancer. — Cancer  of  the  Duodenum. — 
This  is  a  rare  condition.  There  are  the  anemia  and  cachexia  and  pain 
usually  in  the  right  hypochondriac  region;  this  last  occurs  in  the  midepi- 
gastric  region  or  upper  part  of  abdomen.  The  tumor,  when  palpable, 
is  usually  found  in  the  right  hypochondriac  region,  near  the  middle  line. 
If  it  is  in  the  ascending  part  of  the  duodenum,  there  may  be  fair  mobility; 
if  in  the  descending  or  transverse  parts,  the  tumor  is  only  slightly  movable. 

Nearly  all  the  symptoms  are  referred  to  the  stomach — anorexia,  pains, 
belching,  vomiting,  and  dilatation  of  the  stomach — and  if  the  mass  is  in 
the  ascending  part  of  the  duodenum,  it  will  hardly  be  possible  to  differen- 
tiate it  from  gastric  tumor  without  operation.  Blood  may  be  mixed 
with  the  vomitus. 

Boas  makes  use  of  the  terms  suprapapillary,  infrapapillary,  and  circum- 
papillary  carcinoma,  according  to  the  position  of  the  growth  relative  to  the 
papilla  of  Vater. 

If  the  carcinoma  is  suprapapillary,  we  have  stenosis  of  the  upper  part 
of  the  duodenum,  and,  as  already  noted,  symptoms  identical  with  pyloric 
stenosis,  from  which  it  can  hardly  be  differentiated. 


NEOPLASMS    OF    THE   INTESTINES 


773 


With  infrapapillary  carcinoma  the  gastric  symptoms  again  pre- 
dominate, but  there  are  stasis  of  bile  and  pancreatic  juice,  and  regurgita- 
tion of  these  secretions  into  the  stomach;  bilious  vomiting  is  frequent. 
The  vomiting  is  intermittent  and  the  symptoms  those  of  obstruction. 
Trypsin  should  be  tested  for  in  the  vomit  by  observing  whether  fibrin 
is  digested  in  an  alkaUne  solution.  This  would  differentiate  from  a 
gastrohiliary  fistula. 

Circumpapillary  carcinoma.  In  the  pure  cases  surrounding  the  papilla 
of  Vater,  jaundice,  anemia,  and  cachexia  slowly  increase  in  severity,  with- 
out any  gastro-intestinal  symptoms,  and  pain  is  usually  absent.     Some  of 


Fig.  315. — Cancer  of  the  region  of  the  papilla  of  Vater  emanating  from  the  common 

duct  (after  Letulle). 

these  cases  doubtless  have  their  origin  in  the  wall  of  the  ductus  communis 
choledochus  as  it  passes  through  the  wall  of  the  duodenum  as  in  Fig.  315. 

Chills  may  at  times  occur  and  cholangitis  may  be  a  complication. 
Jaundice  may  vary  in  intensity  or  may  be  intermittent.  When  the  tumor 
involves  the  common  bile-duct  and  head  of  the  pancreas  jaundice  is  pro- 
gressive and  continuous.  Ulceration  may  temporarily  open  a  passage 
for  the  bile.     Gastric  symptoms  may  occur  in  addition. 

The  tumor  can  be  palpated  deep  down  in  the  right  hypochondriac 
region  near  the  middle  line.     At  times  it  cannot  be  discovered. 

Carcinoma  of  the  duodenum  is  a  disease  of  late  middle  or  advanced 
life,  occurring  most  often  in  males. 

The  second  part  of  the  duodenum  is  most  frequently  involved,  and 
next  in  frequency  the  first  part. 


774  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Carcinoma  of  the  small  intestine  (jejunum  and  ileum)  is  rare.  The 
symptoms  vary,  depending  on  the  position  of  the  growth;  the  higher  up, 
the  more  marked  are  the  gastric  symptoms;  the  lower  down,  the  more 
severe  the  intestinal  symptoms. 

There  may  be  anorexia  and  vomiting,  or  fair  appetite  and  good  stomach 
digestion,  but  obstinate  constipation. 

General  Symptoms. — In -both  conditions  there  are  anemia  and  cachexia, 
physical  depression,  indigestion  characterized  by  rumbling  belching  and 
a  sense  of  weight;  pain,  borborygmi  attacks  of  colic  and  constipation  which 
may  alternate  with  a  diarrhea.  There  is  often  a  feeling  of  incomplete 
emptying  of  the  bowels  after  a  movement.  There  may  be  mucus,  pus 
or  blood  in  small  amount  in  the  stool.  There  may  occasionally  be  larger 
hemorrhages  from  the  bowel  if  the  growth  is  low  down.  Loss  of  weight 
occurs.  The  clinical  symptoms  of  stenosis  of  the  intestines  may  be  present. 
The  tumor  is  at  times  accessible  to  palpation,  and  is,  as  a  rule,  extremely 
movable.  It  may  be  so  much  displaced  downward  that  it  is  difficult  to 
draw  an  accurate  conclusion. 

Local  S3rmptoms  of  Carcinoma  of  the  Large  Intestine. — Cachexia 
and  anemia  are  present.  Pain  is  a  frequent  symptom;  it  may  not  be 
present  at  first,  usually  appears  later  in  the  disease,  and  becomes  local- 
ized; in  some  cases,  running  an  acute  course,  no  pain  appears  until  the 
symptoms  of  acute  obstruction  begin.  Pain  is  usually  localized;  it  may 
appear  near  or  at  the  region  of  the  growth,  or  occasionally  directly 
opposite,  in  the  abdomen. 

The  pain  may  not  be  severe,  but  may  be  more  a  sense  of  discomfort. 
There  may  be  neuralgia  of  the  sciatic  or  anterior  crural  nerves.  Later 
pain  usually  becomes  localized,  and  is  increased  on  pressure,  even  if  the 
tumor  cannot  be  palpated.  It  may  be  due  to  local  peritonitis  near  the 
tumor. 

Attacks  of  colic  often  occur,  local  or  diffuse.  The  pains  may  be  quite 
severe,  are  accompanied  with  constipation,  and  are  relieved  by  diarrhea 
or  by  the  passage  of  flatus.  These  attacks  of  colic  are  frequently  caused 
by  the  commencing  obstruction,  and  show  gradually  progressive  stenosis. 
Peristaltic  and  tetanic  movements  of  the  intestines  are  often  associated. 
Complete  obstruction  may  suddenly  develop,  or  there  may  be  a  gradually 
progressive  stenosis  with  its  symptoms. 

Constipation  is  one  of  the  marked  symptoms;  in  some  cases  it  may  be 
first,  and  becomes  gradually  progressive. 

Ten  to  twenty  or  even  eighty-eight  days  have  passed,  according  to 
various  observers,  before  the  bowels  moved  spontaneously  or  by  artificial 
means.  These  were,  of  course,  extreme  cases.  The  majority  of  patients 
have  symptoms  of  commencing  or  complete  obstruction  after  coprostasis 
has  lasted  a  week  or  ten  days.  This  has  been  my  experience  in  consulta- 
tion practice.  Recently  I  saw  a  case  for  the  first  time  on  the  fourth  day 
of  coprostasis  when  acute  symptoms  were  present.  Loss  of  appetite, 
tension,  fulness  in  the  abdomen,  and  pain  accompany  the  constipation. 
Spontaneous  diarrhea  may  relieve  the  condition.  If  this  does  not  occur, 
or  relief  is  not  afforded  artificially,  gradual  occlusion  will  take  place  with 
its  typic  symptoms. 


NEOPLASMS    OF    THE   INTESTINES  775 

In  some  patients  diarrheal  movements  may  occur  for  several  weeks, 
due  to  the  catarrhal  condition  of  the  bowel  or  ulceration  of  the  growth. 

Stools. — In  some  cases  of  carcinoma  the  stools  may  be  normal  and 
simply  hard  in  character  when  constipation  is  present. 

In  others  they  may  be  in  small  balls  like  sheep's  dung,  flattened,  or 
ribbon  shaped. 

Mucus  shows  the  presence  of  catarrh  of  the  mucous  membrane.  The 
presence  of  pus  in  the  stools  is  of  importance,  but  only  appears  when  the 
growth  ulcerates;  hence  its  absence  does  not  prove  there  is  no  tumor. 
Microscopic  examination  for  pus  is  indicated. 

Pus  in  some  cases  may  be  derived  from  an  abscess  cavity  opening  into 
the  intestines. 

The  same  remarks  hold  true  of  blood,  the  amount  found  is  usually 
small,  and  violent  hemorrhages  are  rare;  at  times  only  occult  blood  can 
be  determined. 

The  appearance  of  pus  and  blood  in  the  stool  in  a  patient  with  symptoms 
of  stenosis  of  the  ho-^el  favors  the  diagnosis  of  malignancy.  Occult  blood 
should  be  tested  for  if  none  is  visible. 

If  there  is  gangrenous  disintegration  of  the  tumor,  the  odor  is  very 
characteristic,  and  occasionally  small  bits  of  new  growth  may  be  found  in 
the  stool. 

Tumor. — The  presence  of  palpable  tumor  strengthens  the  diagnosis. 
It  may  be  no  larger  than  a  nut,  or  the  size  of  a  child's  head,  and  be  solid 
and  hard  like  cartilage.  If  there  is  much  infiltration,  it  may  give  the  sen- 
sation of  a  solid  and  thick  cord.  These  tumors  are  generally  moderately 
tender  on  pressure,  in  some  cases  quite  so;  occasionally  they  are  not  tender 
at  all.  Their  great  mobility  is  characteristic.  On  palpation  they  are  easily 
moved  about,  especially  in  the  sigmoid  and  transverse  colon;  fecal  accumu- 
lation readily  displaces  the  tumor  and  it  may  become  adherent  in  an  ab- 
normal position.  Occasionally  peristaltic  movements  may  cause  it  to 
appear  and  disappear  during  palpation.  Respiratory  mobility  of  the 
tumor  also  may  occur  if  it  be  in  the  transverse  colon,  or  if  it  be  adherent 
to  the  liver,  spleen,  or  stomach. 

Large  amounts  of  fecal  material  may  accumulate  above  the  growth, 
and  we  must  clear  this  material  out  by  irrigation  and  laxatives,  so  as  to 
determine  the  extent  of  the  tumor.  The  region  of  the  liver  must  be  ex- 
amined for  metastases  and  the  rectum  palpated  to  see  if  the  primary 
growth  lies  there. 

A  pure  fecal  tumor  may  lead  to  narrowing  and  occlusion.  These  last 
tumors  are  more  doughy,  less  firm,  and  quite  frequently  multiple. 

Differential  Diagnosis. — We  must  remember  that  old,  agglutinated 
masses  from  recurrent  appendicitis  may  simulate  cecal  tumor.  The  his- 
tory is  an  aid.  Moreover,  tumor-like  tuberculosis  of  the  cecum  may  simu- 
late malignant  growth.  In  these  cases  there  may  be  pulmonary  tuberculo- 
sis, a  previous  history  of  diarrhea,  or  the  presence  of  tubercle  bacilli  in 
the  stools.  Some  cases  cannot  be  differentiated.  The  tuberculin  test 
aids  diagnosis. 

Leube  called  to  our  attention  that  chronic  inflammation  of  the  sigmoid 
mav  occur  and  be  mistaken  for  carcinoma.     Undoubtedlv  these  cases  are 


776  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

so-called  peridiverticulitis,  with  chronic  thickening,  and  often  stenosis  of 
the  sigmoid  simulating  carcinoma.  These  patients  are  generally  over 
sixty  years  of  age,  fat  and  flabby,  or  they  have  been  fat  previous  to  emacia- 
tion. There  is  often  a  history  of  acute  left-sided  inflammation  and  gen- 
erally of  prolonged  constipation.  One  must  remember  the  possibility  of 
this  condition.  Blood  and  pus,  as  a  rule,  are  absent  from  the  stools  in  these 
patients.  Often  it  is  impossible  to  differentiate  these  conditions,  even 
after  resection,  except  by  the  microscope. 

Cachexia  and  anemia  are  always  present  in  cancer. 

Primary  Carcinoma  of  the  Appendix. — This  condition  has  been  con- 
sidered rare,  but  it  has  been  demonstrated  to  occur  more  frequently  than 
was  formerly  supposed.  (See  Appendicitis.)  Most  of  the  cases  give 
symptoms  of  relapsing  appendicitis  or  appendicitis;  53  per  cent,  are  under 
thirty  years,  and  24  per  cent,  under  twenty.  This  condition  has  only 
been  detected  after  operation  on  the  appendix.  The  carcinoma  is  sphe- 
roidal celled. 

Carcinoma  of  the  Rectum. — This  is  the  most  frequent  type  of  cancer, 
is  more  readily  diagnosed,  and  more  amenable  to  treatment  if  early  opera- 
tion is  performed.  Many  of  the  tumors  are  within  reach  of  the  finger. 
The  symptoms  resemble  those  of  carcinoma  of  the  colon,  though  there  are 
certain  signs  peculiar  to  this  condition.  Rectal  examination  should 
always  be  made. 

Pain  is  more  pronounced  in  rectal  carcinoma,  both  local  and  radiating 
to  the  sacrum,  back,  bladder,  genitals,  and  to  the  sciatic  nerve;  there  is 
often  a  desire  to  urinate.  The  pain  is  usually  worse  during  defecation  if  the 
growth  is  low  down,  and  it  may  even  be  agonizing  in  character,  so  much 
so  that  the  patients  try  to  retain  the  bowel  contents  as  long  as  possible. 

Marked  tenesmus  is  present,  and  if  ulceration,  mucus,  blood,  and  pus 
are  evacuated.  Constipation  is  usually  present.  The  higher  up  in  the 
rectum,  the  more  the  symptoms  resemble  those  of  cancer  of  the  sigmoid. 
Tenesmus  may  be  absent  if  the  growth  is  high  up.  Diarrhea  may  at  times 
supervene;  occasionally,  after  sloughing  of  the  tumor,  paralysis  of  the 
sphincter  occurs. 

Leube  was  the  first  to  call  attention  to  the  fact  that  hemorrhoids  fre- 
quently developed  with  carcinoma  of  the  rectum,  and  that,  too,  at  an  early 
stage.  Piles  occurring  suddenly,  and  not  developing  slowly  or  existing  for 
many  years,  are  suggestive. 

Rectal  examination  is  most  important,  and  the  finger  will  usually  give 
the  necessary  information.  One  can  feel  a  mass  lying  directly  beneath 
the  mucous  membrane  or  adherent  to  it.  The  surface  may  feel  uneven 
and  hard  or  there  may  be  occasionally  a  cauliflower  or  mushroom  growth, 
or  a  constriction,  through  which  the  finger  cannot  readily  pass.  If  it  be 
barely  possible  to  feel  the  growth,  it  is  similar  in  sensation  to  the  cervix 
uteri. 

Blood,  pus,  or  sanious  material  may  be  found  on  the  finger  if  the  growth 
is  ulcerating. 

Vaginal  examination  in  women  must  be  made  to  differentiate  the  source 
of  the  tumor.  The  genito-urinary  organs  in  the  male  should  also  be 
examined. 


NEOPLASMS   OF   THE   INTESTINES  777 

Simple  cicatricial  stricture  is  usually  smooth  and  not  ulcerated,  while 
a  carcinomatous  stricture  is  usually  nodular  and  frequently  ulcerated. 

It  is  preferable  for  accurate  diagnosis  to  excise  a  portion  under  cocain 
for  microscopic  examination. 

If  the  stricture  cannot  be  reached  by  the  finger,  Kelly's  speculum  is  of 
value.     Never  insert  the  hand  into  the  rectum. 

Metastatic  growths  in  other  organs  are  quite  frequent  from  small  growths 
of  the  rectum ;  thus,  with  carcinoma  of  the  liver,  a  small  primary  carcinoma 
of  the  rectum  may  be  found,  even  if  no  symp.toms  are  present. 

The  bladder  and  vagina  may  be  involved  and  fistulous  openings  occur. 
Periproctitis  (abscess)  and  fistulae  are  rare. 

The  peritoneum  is  rarely'involved  unless  the  carcinoma  is  high  up. 

Course. — The  termination  is  death  if  not  operated  on.  This  may 
occur  by  occlusion  of  the  intestines  and  from  peritonitis. 

•  It  is  hardly  possible  to  give  a  prognosis  as  to  duration.  In  cancer  of 
the  duodenum  the  general  nutrition  suffers  early,  or  the  case  may  be  very 
acute  and  the  duration  of  life  is  short.  In  many  cases  the  course  varies 
from  six  months  to  two  years,  while  in  rectal  cancer  it  may  last  for  three 
to  even  four  years.     Rarely  cases  come  to  a  standstill  and  last  some  years. 

In  some  cases  coma  (carcinomatosum)  appears  quite  early,  probably 
due  to  auto-intoxication  from  intestinal  decomposition  or  from  the  toxins 
of  cancer  or  the  patient  may  become  melancholic.  Ewald  isolated  a  body 
from  the  urine  belonging  to  the  group  of  diamins  in  such  a  case. 

Thrombosis  may  develop  and  embolus  of  the  lungs  occur,  with  death 
resulting.  If  obstructions  do  not  occur,  death  may  occur  from  exhaustion 
or  these  patients,  becoming  asthenic  and  bed-ridden,  may  develop  hypo- 
static congestion  of  the  lungs  or  cancerous  infiltration  of  the  same.  With 
hypostasis  there  are  irregular  temperature,  rapid  and  feeble  pulse,  in- 
creased rapidity  of  respiration  and  gradually  listlessness  *or  a  dormant 
or  somnolent  condition,  merging  into  semi-coma,  coma  and  finally  death. 
Preceding  the  latter  there  are  usually  fecal  and  urinary  incontinence 
as  terminal  symptoms. 

Diagnosis. — Presence  of  a  tumor  by  abdominal  palpation  or  rectal 
examination,  accompanied  by  cachexia  (loss  of  weight  marked)  and  ane- 
mia, with  marked  constipation  and  increasing  symptoms  of  stenosis  of  the 
bowel;  or  cachexia,  intestinal  disturbances,  with  no  detectable  tumor,  but  with 
symptoms  of  progressive  stenosis  in  an  elderly  person,  are  suggestive  of  cancer. 
Examination  of  a  tumor  fragment,  if  it  can  be  secured  in  the  stool  or  from 
the  rectum,  is  conclusive.  Inflation  per  rectum  of  the  intestines  with  air 
or  with  water  is  of  service.  In  many  cases  most  of  the  enema  will  at  once 
be  returned. 

X-rays. — The  of-rays  are  of  particular  value  in  demonstrating  a  stenosis 
due  to  the  growth.  Bismuth  or  barium  may  be  given  by  mouth  and 
radiographs  be  taken  6,  8  and  24  hours  later.  There  is  an  accumulation 
above  the  stricture  and  a  narrow  zone  passing  through  it.  A  barium 
enema  can  be  given  and  a  second  series  of  radiographs  be  taken. 

P*rognosis. — This  is  fatal,  unless  a  radical  operation  is  performed. 

Treatment. — Complete  and  early  removal  of  the  growth  is  indicated. 
An  early  diagnosis  is  important.     If  abdominal  cancer  is  suspected,  ex- 


778  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

ploratory  laparotomy  and  complete  resection  of  the  growth,  with  end-to-end 
or  lateral  anastomosis,  are  indicated. 

If  resection  is  impossible,  entero-enterostomy  or  enterocolostomy  for 
drainage  to  relieve  symptoms  is  indicated. 

If  the  tumor  is  low  down  in  the  colon,  sigmoid,  or  rectum  and  inop- 
erable, then  colostomy  to  relieve  the  symptoms  and  prevent  irritation  of 
the  surface  of  the  cancer. 

In  the  rectum,  resection,  preferably  Kraske's  operation,  is  indicated  if 
radical  operation  is  possible. 

Palliative  curetment  and  the  thermocautery  may  be  employed  in  some 
cases.     Colostomy  under  cocain  can  be  performed  in  the  aged  and  feeble. 

Coley's  treatment  by  erysipelas  toxins  may  be  tried,  but  I  would  not 
recommend  it.     It  is  more  successful  with  sarcoma. 

Diet. — Soluble  foods  with  little  residue,  such  as  milk,  broths,  bouillon, 
tropon,  somatose,  cream,  butter,  rice-gruel,  sour  milks,  matzoon  koumiss, 
fermillac,  bacillac,  raw  eggs,  etc.,  are  indicated. 

Irrigation  of  the  intestines,  enemata,  and  injections  with  olive  oil,  and 
internally,  castor  oil,  magnesium  sulphate,  rhubarb,  cascara,  regulin, 
mineral  oil,  olive  oil,  etc.,  to  keep  movements  soft;  warm  applications  to 
the  abdomen;  morphin,  codein,  and  belladonna  are  indicated  for  pain. 
These  last  can  be  given  by  suppository.  Strength  should  be  supported 
by  tonics,  iron,  arsenic,  etc.,  and  pain  relieved.  Treat  complications. 
Opiates  should  be  employed  only. when  absolutely  necessary. 

SARCOMA  AND  LYMPHOSARCOMA  OF  THE  INTESTINES 

Sajrcoma  of  the  intestines  is  rather  an  infrequent  disease,  much  less 
frequent  than  carcinoma.  In  the  course  of  twelve  years,  1882-93,  in  the 
Vienna  General  Hospital,  out  of  274  autopsies  on  patients  dying  of  sar- 
coma, only  3  were  sarcoma  of  the  intestines,  the  ileum,  cecum,  and  rectum. 
In  61  cases  of  lymphosarcoma,  9  belonged  to  the  intestines,  i  in  the  duo- 
denum, 3  in  the  jejunum,  3  in  the  ileum,  and  2  in  the  cecum. 

Of  Libman's  cases,  15  were  of  the  duodenum,  18  of  the  jejunum  and 
ileum,  14  of  the  ileum,  and  3  of  the  entire  small  intestine. 

Sarcoma  occurs  as  frequently  in  the  small  as  in  the  large  intestine,  and 
lymphosarcoma  preponderates  in  the  small  bowel. 

Of  Krueger's  37  cases,  16  were  of  the  small  bowel  alone  and  16  of  the 
rectum;  the  ileocecal  region  comes  next. 

Sarcomata  generally  attain  a  large  size,  even  as  large  as  a  child's  head 
and  spread  over  a  large  part  of  the  intestines. 

Anatomy. — Sarcomata  usually  originate  in  the  submucosa,  the  muscula- 
ture is  attacked  early,  and  the  serosa  is  rarely  involved.  Small  round- 
celled  sarcoma  is  most  frequent;  occasionally  spindle-celled.  In  the  rec- 
tum they  are  often  melanotic. 

Lymphosarcomata  start  from  the  lymphatic  apparatus,  the  solitary 
and  agminate  lymph-follicles.     These  occur  chiefly  in  the  small  intestine. 

Sarcomata  of  the  intestines  show  a  rapid  progress  and  metastases  are 
found  early.  They  do  not  produce  stricture  of  the  bowel,  but  a  dilatation,  and 
develop  in  a  longitudinal  direction  along  the  intestines.  The  bowel  may  be 
enormously  dilated.     Rectal  sarcoma,  however,  may  produce  obstruction. 


NEOPLASMS   OF    THE    INTESTINES  779 

Age. — Sarcoma  is  frequent  in  young  persons;  most  frequent  from 
twenty  to  forty  years  of  age;  from  four  to  seventy  years  cases  are 
reported,  and  one  congenital  case  in  an  infant  three  days  old. 

Symptoms. — The  clinical  symptoms  differ  from  carcinoma.  The  gen- 
eral health  becomes  impaired  early.  The  patients  emaciate  rapidly  and 
become  anemic.  There  is  peculiar  want  of  proportion  between  the  rapid 
impairment  of  the  physical  condition  and  the  absence  of  local  symptoms. 
They  become  rapidly  weak  and  debilitated  (cachexia).  They  are,  as  a 
rule,  an  absence  of  abdominal  pain  and  no  symptoms  of  stenosis.  Intes- 
tinal symptoms  are  slight — occasionally  constipation,  alternating  with 
diarrhea. 

Exceptionally,  stenotic  symptoms  appear,  due  to  kinking  or  peritonitic 
incarceration,  or,  rarely,  ileus.     Stenosis  occurs  in  rectal  carcinoma. 

The  tumor  appears  early,  grows  rapidly,  and  can  easily  be  made  out. 

Duration. — The  majority  of  cases  die  within  nine  months  from  general 
cachexia  or  pulmonary  involvement,  or  from  hypostatic  congestion  of  the 
lungs;  only  one  case  recorded  lived  twenty-one  months. 

Prognosis. — This  type  of  tumor  proves  fatal,  and  even  early  operation 
seems  of  no  value  on  account  of  the  metastases. 

Treatment. — Injection  of  Coley's  fluid,  the  mixed  toxins  of  erysipelas 
and  Bacillus  prodigiosus,  is  indicated,  as  in  inoperable  sarcoma  in  the  other 
regions.  One  must  remember  that  marked  reaction  follows  the  injection 
in  some  cases,  and  some  patients  cannot  undergo  the  treatment.  I  have 
seen  the  latter  occur,  and  also  in  another  case  temporary  improvement. 

The  patient  should  receive  as  liberal  a  diet  as  possible,  and  iron,  arsenic, 
and  cod-liver  oil  should  be  administered.  As  a  rule,  no  stenosis  is  present, 
but  if  in  evidence,  operative  procedure  is  indicated.  Removal  has  failed 
on  account  of  the  metastases. 

BENIGN  TUMORS  OF  THE  INTESTINES  (NEOPLASMS) 

Benignant  neoplasms  of  the  intestines  are  relatively  rare,  and  their 
clinical  significance  is  generally  slight.  They  occasionally  produce  severe 
symptoms. 

These  tumors  may  be  attached  to  the  bowel  wall  by  a  broad  base  or 
by  a  thin  pedicle  or  stem,  and  are  then  termed  polypi.  The  last  type  is 
usually  of  small  size,  that  of  a  cherry,  but  rarely  as  large  as  a  pear,  and 
occur  most  frequently  in  the  rectum. 

The  following  forms  of  benign  tumor  are  found:  Adenoma,  fibroma, 
lipoma,  papilloma,  myoma,  fibromyoma,  angioma,  and  chylangioma. 

Adenomata  are  most  frequently  met  with.  They  arise  from  the  glands 
of  Lieberkiihn  and  in  the  duodenum  from  Brunner's  glands;  are  acinous  in 
structure,  and  may  be  attached  to  the  bowel  by  a  broad  base  or  by  a 
pedicle.  As  a  rule  they  are  small,  the  size  of  a  pea;  rarely,  the  size  of  a 
pear.  They  are  red  and  have  a  tendency  to  bleed;  usually  they  are  soft 
and  the  surface  is  smooth,  though  occasionally  of  a  cauliflower  appearance. 
They  occur  most  frequently  in  the  rectum,  are  usually  polypoid,  though 
occasionally  annular  and  flat.  They  are  most  common,  in  this  location, 
in  children  of  from  four  to  seven  years,  though  occasionally  found  in  adults. 
More  than  half  the  cases  that  occur  are  in  males  between  sixteen  and 


780  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

thirty  years  of  age.  Sometimes  there  is  extensive  involvement  of  the 
intestines,  a  condition  known  as  polyposis  intestinalis  adenomatosa;  in 
one  case  several  thousand  were  present.  Polypi  are  never  limited  to  the 
small  intestine.     Carcinomatous  degeneration  of  the  polypi  may  occur. 

Fibroma,  Lipoma,  Papilloma. — These  neoplasms  derived  from  the 
connective  tissues,  especially  from  the  submucosa,  are  very  rare.  They 
are,  as  a  rule,  lipomatous  in  structure,  and  often  originate  from  the  appen- 
dices epiploicae.  They  frequently  project  into  the  peritoneal  cavity  and 
may  twist  their  pedicle  and  become  detached.  They  may  have  a  broad 
base  or  pedicle,  are  of  various  shapes,  and  may  grow  to  the  size  of  an  apple. 
They  occur  most  frequently  in  the  colon  and  rectum,  less  frequently  in 
the  jejunum,  and  rarely  in  the  ileum. 

Myoma,  Fibromyoma. — These  are  very  rare,  and  usually  originate 
from  the  outer  muscular  coat  of  the  intestines,  chiefly  from  the  longitudinal 
coat.  There  are  two  forms:  Spheric  nodules,  which  grow  toward  the 
mucous  lining  and  sometimes  become  pedunculated,  the  mucous  mem- 
brane lying  loose  in  front;  or  they  may  have  a  broad  thick  base,  forming  a 
circumscribed  thickening,  the  mucous  membrane  being  adherent. 

Rarely  the  myoma  will  grow  toward  the  peritoneal  cavity. 

Angiomata. — These  are  exceedingly  rare,  and  may  occur  as  a  telan- 
giectatic mass,  or  as  a  flat  vascular  tumor  involving  more  or  less  of  the 
bowel  wall.     Cystic  chylangiomata  occur  in  the  small  intestine. 

Sjmiptoms. — In  many  cases  there  are  no  symptoms  at  all,  and  the  con- 
dition is  discovered  accidentally  postmortem. 

Sometimes  they  give  rise  to  intestinal  hemorrhage.  When  this  occurs 
in  a  person  in  good  health,  who  has  never  given  any  history  of  previous 
intestinal  trouble,  the  possibility  of  an  intestinal  tumor  should  be  thought 
of.     This  is  especially  true  in  children. 

Diarrhea  with  blood  and  mucus  have  been  reported  in  cases  of  poly- 
posis intestinalis  adenomatosa.  On  account  of  their  small  size  it  is  nearly 
impossible  to  discover  them  by  palpation. 

Symptoms  may  rarely  be  produced  by  narrowing  or  occlusion  of  the 
bowel  by  the  intestinal  tumor,  or  from  an  intussusception  caused  by  the 
tumor.  When  tumors  are  situated  in  the  rectum  disturbances  are  most 
likely  to  occur,  such  as  hemorrhage,  passage  of  mucus,  tenesmus,  and 
difficult  defecation. 

Sometimes  the  mass  may  be  felt  by  the  examining  finger,  and  it  may 
even  protrude  from  the  anus  and  give  rise  to  severe  pain.  It  may  occa- 
sionally be  torn  off  and  passed  with  the  stools,  when  the  symptoms  may 
disappear. 

Course. — They  may  remain  latent  or  give  symptoms  for  some  years 
and  then  be  passed  per  rectum. 

Treatment. — Intestinal  hemorrhage  should  be  treated  in  the  manner 
already  described  under  Typhoid.  The  blood  will  often  be  bright  in  color 
if  the  hemorrhage  is  from  the  colon  or  rectum ;  injection  of  very  hot  or  cold 
water  with  i  dram  (4.0)  of  alum  or  tannic  acid,  30  grains  (2.0),  locally,  or 
Tremoliere's  solution,  by  mouth  and  rectum;  ice-bag  to  the  abdomen; 
morphin,  }i  grain  (0.016),  and  ernutin,  5  minims  (0.296),  by  hypodermic, 
are  indicated. 


NEOPLASMS    OF    THE    INTESTINES  78 1 

If  the  tumors  are  accessible  in  the  rectum,  they  should  be  removed  by 
galvanocautery  or  by  operation. 

Ligation  and  excision,  after  water  infiltration  of  the  pedicle,  is  an  ex- 
cellent method.  When  the  polypi  are  higher  up,  each  may  be  exposed  in 
turn  by  the  aid  of  the  proctoscope.  A  Gant  valve  clamp  may  be  snapped 
on  the  pedicle  of  each  and  they  may  then  be  allowed  to  slough  off.  This 
last  method  is  extremely  simple  and  requires  no  anesthetic.  When  the 
growths  are  very  numerous,  large  or  ulcerated,  and  scattered  throughout 
the  colon  or  sigmoid  flexure,  cecostomy  with  irrigation  of  the  bowel,  or 
in  some  cases  extirpation  of  the  diseased  portion  may  be  necessary. 

GAS  CYST  OF  THE  INTESTINES 
(Synonym. — Pneumatosis  Cystoides  Intestinorum  Hominis) 

Cysts  containing  air,  in  the  intestines  of  pigs,  were  probably  first 
described  by  Mayer, ^  of  Bonn.  This  condition  was  also  independently 
described  by  John  Hunter.  These  intestinal  gas  cysts  have  been  found 
quite  frequently  in  apparently  otherwise  healthy  pigs  and  occasionally  in 
sheep.  The  theory  has  been  held  that  bacteria  are  the  cause,  or  that  they 
are  the  result  of  mechanical  and  physical  conditions;  for  example,  that 
gas  may  escape  through  some  abrasion  into  the  tissues.  Others  believe 
the  process  is  analogous  to  a  traumatic  emphysema.  Bang^  first  reported 
this  condition  in  the  human  being,  and  Finney  the  first  case  in  America. 

Finney  and  Welch^  believe  the  cyst  to  be  a  distinct  variety  of  tumor, 
the  cells  of  which  have  the  faculty  of  secreting  gas.  In  practically  every 
case  so  far,  the  gaseous  cyst  has  been  associated  with  disease  of  some  por- 
tion of  the  gastro-intestinal  canal,  in  some  cases  producing  an  obstruction 
to  the  lumen  of  the  bowel.  Turnure^  has  reported  an  interesting  case 
with  a  careful  investigation  of  the  subject.  Practically  all  the  cases  with 
autopsy  show  the  presence  of  gastric  or  duodenal  ulcers  or  of  symptoms 
pointing  to  some  chronic  disease  of  the  intestinal  tract  of  long  duration. 
Cysts  may  be  single  or  multiple  and  occur  in  the  small  and  large  intestines. 

Pathology. — There  is  a  dense  fibrous  tissue  framework  containing  round 
and  spindle  cells,  and  there  are  clefts  and  spaces  whose  walls  contain 
large  giant  cells  with  many  nuclei.  Air  spaces  are  found  about  these  cells, 
and  there  is  an  endothelial  lining  to  these  spaces.  The  blood-supply  is 
rich  and  hemorrhages  may  occur  in  the  tissues.  Air  in  the  cyst  resembles 
atmospheric  air.  The  tumor  is  more  pronounced  in  the  subserous  tissue, 
though  it  has  been  observed  in  all  the  layers  of  the  walls. 

Clinically,  there  is  no  definite  picture.  Crepitation  on  palpation  has 
been  noted.  Pain  and  constipation  could  be  chiefly  attributed  to  other 
factors. 

Diagnosis  is  usually  made  during  operation  for  some  other  trouble  or 
at  autopsy. 

Treatment. — If    symptoms   of    obstruction,    operation   is   indicated. 

After  operation  for  other  conditions,  they  generally  diminish  in  size  or 

disappear. 

^  Jour.  d.  prakt.  Heilk.,  1825. 
2  Nord.  med.  Ark.,  1876,  viii,  No.  18. 
'Jour.  Amer.  Med.  Assoc,  October  17,  1908. 
*  Annals  of  Surgery,  June,  1913. 


CHAPTER  XXX 

HEMORRHOIDS;  PROLAPSE  OF  RECTUM;  FISSURE;  ABSCESS 
OF  THE  RECTUM;  PRURITUS  ANI;  FISTULA  IN  ANO 

HEMORRHOroS 

{Synonyms. — Phlebectasia  Hemorrhoidalis;  Piles) 

Hemorrhoids  consist  of  dififuse  or  circumscribed  varicose  dilatations 
of  the  hemorrhoidal  veins,  lying  either  in  the  subcutaneous  tissue  of  the 
anus  external  to  the  sphincter  (external  hemorrhoids)  or  in  the  submucous 
tissue  of  the  lower  portion  of  the  rectum  (internal  hemorrhoids). 

The  hemorrhoidal  veins  surround  the  lower  portion  of  the  rectum  and 
there  form  the  hemorrhoidal  plexus.  The  majority  of  these  veins  enter  into 
the  inferior  or  external  inferior  hemorrhoidal  veins,  and  from  there  into 
the  common  pudic  and  iliac  veins;  others  pass  into  the  median  inferior 
hemorrhoidal  veins  and  so  into  the  internal  iliac  vein  and  the  inferior  vena 
cava.  A  small  number  of  the  veins  enter  the  superior  hemorrhoidal  veins, 
thence  into  the  inferior  mesenteric  veins  and  the  portal  system. 

In  portal  obstruction  blood  from  the  hemorrhoidal  plexus  can  pass  into 
the  vena  cava;  while  back  pressure  on  the  vena  cava  inferior,  when  of 
cardiac  origin,  may  aflfect  the  hemorrhoidal  system.  All  hemorrhoidal 
veins  are  devoid  of  valves. 

Anatomy. — External  hemorrhoids  are  visible  to  the  naked  eye,  lie 
below  the  sphincter  ani,  and  are  often  arranged  in  groups  around  the  anal 
orifice.  They  appear  as  bluish-red,  tortuous  vessels  encircling  the  open- 
ing; or  there  may  be  isolated  varicose  protrusions,  from  the  size  of  a  pea 
to  a  walnut.  They  may  be  round,  flat,  or  irregular  in  shape,  and  their 
size  sometimes  changes  in  the  same  patient,  often  being  smaller  after 
defecation. 

Internal  hemorrhoids  often  can  only  be  discovered  by  digital  examina- 
tion or  by  use  of  the  proctoscope,  as  they  lie  above  the  sphincter.  In 
aggravated  cases  the  patient  by  bearing  down  may  cause  them  to  protrude. 
They  usually  appear  as  soft  nodules  of  bluish  hue,  with  thin  walls. 

The  diffuse  or  circumscribed  nodular  forms  may  be  present,  and  the 
last  constitute  a  true  varix. 

External  and  internal  hemorrhoids  may  occur  together.  Piles  may 
occur  singly  or  in  pairs,  or  be  multiple  and  form  a  ring  about  the  anal 
opening,  both  external  and  internal  to  the  sphincter,  and  even  a  third 
higher  ring  has  been  described.  In  exceptional  cases  dilated  veins  are 
found  high  up  the  rectum,  even  into  the  sigmoid  flexure. 

Hemorrhoids  are  generally  believed  to  be  simple  venous  ectasias  and 
are  considered  genuine  varices,  though  some  maintain  them  to  be  true 
angiomata. 

Secondary  changes  probably  account  for  the  various  conditions  found. 
The  dilated  blood-vessels,  venous  varices,  near  a  group  of  hemorrhoids 

1782 


hemorrhoids;  prolapse  of  rectum;  fissure  783 

may  become  inflamed,  adhere  and  coalesce,  and  the  walls  of  the  vessels 
atrophy,  so  that  tumors  of  some  size,  resembling  cavernous  multilocular 
tumors  (angiomata),  may  develop. 

The  external  covering  of  the  varix  may  become  hard,  thick,  and  resist- 
ant, through  inflammatory  processes.  In  other  cases  the  walls  may  be- 
come thin  and  eventually  rupture,  or  the  blood  coagulate  within  the  pile 
and  form  a  thrombus. 

Phleboliths  occur  in  old  cases.     A  blood-cyst  is  occasionally  formed. 

Marked  connective-tissue  increase  may  take  place  in  some  of  the  ex- 
ternal hemorrhoids;  they  may  present  the  appearance  of  skin  tabs,  or  skin 
externally  and  mucous  membrane  internally,  which  may  become  edema- 
tous and  inflamed.     They  may  give  rise  to  warty  growths. 

The  mucous  membrane  of  the  rectum  near  the  hemorrhoids  is  hy- 
peremic,  and,  with  internal  hemorrhoids,  in  a  condition  of  catarrhal 
inflammation. 

Fissure  or  prolapse  of  the  rectum  may  be  associated  with  piles. 

AUingham  has  subdivided  internal  hemorrhoids  into  three  varieties: 

1 .  Capillary  piles,  resembling  nevi,  consisting  of  hypertrophic  capillary 
vessels  and  spongy  connective  tissue  with  thin  mucous  membrane.  They 
easily  bleed. 

2.  Arterial  piles,  sessile  or  pedunculated  tumors,  glistening  or  villous, 
slippery,  hard,  and  vascular. 

3.  Venous  piles,  in  which  the  veins  predominate.  Tumors  are  large 
and  bluish  or  livid  in  color. 

Internal  piles  may  be  pushed  down  during  defecation.  A  pedicle  may 
be  formed  to  the  tumor  and  the  mass  may  slip  out  of  the  rectum.  After 
defecation  they  may  spontaneously  return  into  the  bowel,  or  can  be  re- 
placed. If  large  they  may  become  incarcerated  and  even  gangrenous  and 
slough  off.     Hemorrhage  is  a  common  occurrence. 

Inflammatory  processes  may  complicate  internal  piles,  such  as  ulcers, 
proctitis,  and  periproctitis.  With  the  latter  abscess  may  result,  which 
may  form  fistulae,  external,  internal,  or  complete. 

Etiology. — Hemorrhoids  are  frequently  met  with  in  practice  and  the 
condition  is  much  more  common  than  supposed,  as  many  patients  so 
afflicted  never  consult  the  physician.     It  is  rare  in  children. 

The  statement  is  often  made  that  piles  occur  more  frequently  in  men 
than  in  women.  Undoubtedly  more  male  cases  are  found  in  our  records. 
Habitual  constipation,  pelvic  congestion,  and  sedentary  life  favor  mark- 
edly the  production  of  hemorrhoids,  and  these  conditions  we  find  most 
frequent  in  women.  Males  will  at  once  consult  the  physician  if  there  is 
difficulty  in  the  anal  region.  Women  are,  as  a  rule,  extremely  sensitive, 
and  usually  treat  their  piles  by  home  remedies  until  conditions  are  such  as 
to  necessitate  advice  from  the  physician.  It  has  been  my  experience  that 
most  of  my  women  patients  never  refer  to  "hemorrhoids"  unless  specific- 
ally questioned.  Actually,  I  believe  women  are  the  more  frequently 
afflicted. 

Age. — Piles  occur  most  frequently  between  thirty  and  fifty  years  of 
age.  The  modern  consensus  of  opinion  is  that  hemorrhoids  are  a  local 
disease  and  not  due  to  any  diathesis  or  faulty  state  of  the  general  circula- 


784  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

tion.     There  are  certain  peculiarities  in  the  rectal  plexus  of  veins  favoring 
the  production  of  piles  which  are  as  follows: 

The  walls  of  the  hemorrhoidal  veins  are  thin  and  contain  few  muscular 
fibers,  and  hence  their  contractile  force  is  less  than  that  of  the  veins  in  the 
lower  limbs. 

■  There  are  no  valves  in  the  rectal  veins,  so  that  blood  can  be  readily 
forced  back  into  them.  Muscular  contraction  aids  the  onward  propulsion 
of  the  blood  in  other  regions. 

In  the  rectum  fecal  masses  compress  the  blood-vessels,  the  sphincteric 
contractions  compress  the  vessels,  and  contraction  of  the  abdominal  mus- 
cles during  defecation  interferes  with  the  return  of  blood.  They  are  de- 
pendent blood-vessels,  and  with  the  unfavorable  factors  mentioned  it  is 
not  surprising  that  hemorrhoids  are  frequent. 

Some  of  the  hemorrhoidal  veins  enter  the  portal  system,  in  which  there 
is  a  low  degree  of  pressure  and  in  which  the  circulation  is  readily  retarded. 
Stasis  of  this  system  may  be  a  contributory  factor  in  the  production  of 
hemorrhoids,  as  in  cirrhosis  of  the  liver;  as  may  also  diseases  of  the  heart 
and  lungs  leading  to  engorgement  of  the  venous  system. 

All  conditions  which  tend  to  produce  interference  with  the  return  cir- 
culation of  blood  from  the  hemorrhoidal  vessels,  or  produce  or  predispose 
to  hyperemia,  influence  the  production  of  hemorrhoids.  Among  such  are: 
chronic  constipation;  sedentary  habits,  as  in  clerks,  students,  shoemakers, 
seamstresses,  sitting  on  soft  cushions,  excessive  horseback  riding,^  etc.; 
enlarged  uterus,  as  from  disease  or  pregnancy;  prostatic  afiFections,  tumors 
of  the  bladder,  or  growths  in  the  pelvis. 

Hemorrhoids  may  develop  suddenly  in  cases  of  carcinomatous  stricture 
of  the  rectum  and  early  in  the  course  of  the  disease. 

Habitual  constipation  favors  the  production  of  piles.  Hemorrhoids 
also  may  be  the  primary  condition,  and  on  account  of  the  pain  of  defeca- 
tion the  patient  avoids  having  a  movement  as  long  as  possible.  Excessive 
venery  is  given  as  causing  congestion  in  these  regions.  Abuse  of  alcohol, 
spiced  food,  fatty  food,  excessive  quantities  of  food  and  drink  are  believed 
by  some  to  favor  the  plethoric  habit  and  produce  fulness  of  the  portal  cir- 
culation, with  resulting  piles.  Gourmands  of  this  type  are  often  of  seden- 
tary habit  and  are  frequently  disposed  to  constipation — a  more  likely 
cause.  Von  Recklinghausen  has  shown  that  piles  are  by  no  means  com- 
mon in  plethoric  individuals,  but  more  in  those  of  lean  habit,  of  poor  mus- 
cular development,  with  defective  metabolism,  who  lead  a  sedentary  life, 
and  who  are  anemic,  with  poor  circulation.  Catarrh  of  the  rectum  is 
given  as  a  cause,  but  is  not  always  easy  to  determine  whether  the  catarrh 
or  piles  were  primary.  Drastic  purgatives  are  said  to  produce  hemor- 
rhoids, but  they  are  used  for  the  constipation,  which  may  be  the  chief 
factor.  Cases  do  occur  in  which  it  seems  probable  that  the  excessive  use 
of  purges  has  produced  hemorrhoids  with  prolapse. 

Among  the  Orientals,  who  lead  a  sedentary  life,  hemorrhoids  seem 
quite  common.  Hereditary  anatomic  peculiarities  have  been  suggested 
as  a  cause,  since  piles  are  often  found  in  several  successive  generations. 

Sjrmptoms. — External  Hemorrhoids. — These  are  chiefly  of  local  char- 
1  Bicycle  riding  in  excess  may  be  a  factor. 


hemorrhoids;  pk.olapse  of  rectum;  fissure  785 

acter.  The  patient  may  have  a  sensation  of  fulness,  clogging,  or  pulsation 
in  the  lower  rectum.  At  times  there  may  be  a  feeling  of  obstruction  at 
the  time  of  bowel  movement.     Constipation  usually  precedes  the  attack. 

There  is  itching  of  the  anus  and  perineum.  The  anus  may  be  tender 
and  swollen,  and  if  the  buttocks  are  drawn  apart  external  piles,  single  or 
in  clumps,  round  and  bluish  in  color,  distended  with  blood,  are  present. 
Stains  of  blood  are  often  found  on  the  toilet  paper.  The  exacerbation  may 
quiet  down  under  rational  methods.  They  may  become  swollen  and  edema- 
tous, painful,  and  even  ulcerate  and  suppurate,  with  the  production  of  a 
fistula. 

Tenesmus  may  be  present,  and  the  external  pile  may  be  drawn  up  into 
the  sphincteric  circumference  and  become  pinched  and  strangulated. 
Under  such  conditions  there  are  severe  pain,  throbbing,  a  desire  for  defeca- 
tion with  straining,  and  the  patient  cannot  sit  or  walk  about.  Fever, 
anorexia,  and  severe  constipation  accompany  the  local  manifestations. 

Hemorrhage  is  not  as  marked  with  external  piles. 

Internal  Hemorrhoids. — With  internal  hemorrhoids  hemorrhage  is  often 
a  prominent  symptom.  Frequently  internal  piles  can  only  be  detected 
b^'-  digital  examination  or  by  inspection  through  a  speculum.  They  may 
prolapse  and  even  become  strangulated.  In  such  event  the  pile  becomes 
swollen,  turns  deep  blue,  there  are  agonizing  pain,  marked  tenesmus,  occa- 
sionally vomiting,  constipation,  meteorism,  fainting,  prostration,  and  fever. 

Gangrene  and  sepsis  may  occur  if  the  strangulation  is  not  relieved. 

With  mild  types  of  internal  hemorrhoids  the  only  symptoms  may  be 
an  occasional  hemorrhage.  One  must  remember  that  hemorrhoidal  veins 
may  be  very  high  up  and  only  be  visible  with  a  proctoscope. 

Usually,  subjective  symptoms  are  present,  such  as  itching,  burning, 
pressure  and  weight  in  the  anus,  and  the  sensation  of  a  foreign  body,  with 
tenesmus.  There  may  be  feelings  of  pressure  and  even  pain  in  the  sacral 
and  lumbar  regions.  Occasionally  soreness  over  the  lower  part  of  the 
abdomen,  pressure  in  the  rectum,  bladder,  uterus,  and  vagina;  pains  radi- 
ating to  the  thighs  may  be  present.  Sometimes  these  symptoms  precede 
a  hemorrhage,  after  which  temporary  relief  occurs. 

As  a  rule,  the  bowels  are  irregular  and  constipated; 

Hemorrhages  may  be  frequent,  so  as  to  cause  marked  secondary 
anemia.  In  one  case  notably  the  patient,  a  woman,  from  repeated 
hemorrhages  suffered  from  air  hunger,  dizziness,  faint  spells,  and  even  some 
loss  of  memory.  The  hemoglobin  was  reduced  to  28,  the  red  cells  to 
2,ooo,ooo,Kthe  patient  nearly  dying  as  a  result.  It  was  after  nearly  two 
months  of  most  careful  treatment  before  she  could  be  operated  upon;  the 
result  was  excellent.  Bleeding  may  be  severe  and  bright  red  blood  gush 
from  the  rectum  nearly  pure,  or  it  may  be  dark  brown  mixed  with  fecal 
matter.  In  such  an  event  it  lies  on  the  surface  of  the  feces  and  is  not 
intimately  mixed  with  it.  Small  quantities  of  blood  are  frequently  passed 
with  hard  stools. 

Hemorrhages  sometimes  occur  on  no  special  provocation,  or  after  a 
horseback  or  bicycle  ride,  etc. 

Gummy  acrid  mucus  may  be  discharged  from  the  hemorrhoids  due  to 
catarrh  of  the  rectum,  and  may  cause  excoriations, 
so 


786  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

In  some  the  hemorrhage  may  last  for  several  days  and  temporary 
relief  may  occur.  It  has  been  stated  that  bleeding  from  hemorrhoids 
may  take  the  place  of  menstruation  (vicarious). 

Dyspnea,  palpitation,  angina,  hiccup,  giddiness,  despondency,  and 
hypochondria,  often  attributed  to  piles,  I  believe,  with  Riegel,  are  merely 
associated  with  the  constipation  present,  though  giddiness  and  dyspnea 
may  result  from  hemorrhage  as  in  the  case  cited.  Proctitis,  fissure,  and 
occasionally  abscesses  or  fistulae  may  develop. 

Disturbances  of  adjacent  organs,  such  as  strangury,  hemorrhage  from 
the  bladder  or  vagina,  or  catarrh  of  the  latter  may  occasionally  occur. 

Diagnosis  is  made  by  inspection  and  digital  examination;  occasionally 
the  proctoscope  is  necessary.  The  appearance  of  hemorrhoids  has  been 
described. 

Condylomata  encircle  the  anus  and  are  often  present  on  the  scrotum. 
There  are  a  history  of  syphilis  and  manifestations  of  lues.^ 

Skin  tags  are  whitish  looking,  do  not  change  their  size,  and  do  not  bleed 
when  punctured.     Piles  differ  in  the  last  regard. 

Internal  hemorrhoids  are  reddish  blue  and  bleed  when  manipulated 
or  punctured;  polypi  do  not  do  so.  The  latter  occur  most  frequently 
in  children. 

Carcinoma  presents  a  hard  consistency,  and  produces  stenotic  symp- 
toms and  cachexia.  A  small  section  placed  under  the  microscope  will 
settle  the  diagnosis. 

Piles  may  occur  suddenly  in  association  with  cancer. 

Prognosis. — Piles  are  frequently  a  chronic  affection  and  may  exist 
throughout  life.  In  cases  occurring  during  pregnancy,  restitution  to 
normal  is  possible.  This  is  true  of  the  milder  types  if  the  cause  is  cor- 
rected. They  may  markedly  diminish  in  size  and  then  an  exacerbation 
take  place.  They  rarely  endanger  life  unless  strangulation  with  gangrene 
or  a  large  abscess  or  dangerous  hemorrhage  occur. 

Treatment. — Excesses  of  all  kinds  in  food,  drink,  and  venery  should 
be  avoided.  The  patient  should  lead  an  out-of-door  life,  take  proper  exer- 
cise, and  have  a  daily  soft  evacuation  of  the  bowels. 

All  conditions  causing  venous  engorgement  of  the  rectum  should  be 
avoided,  such  as  constant  standing  or  sitting,  horseback  and  bicycle  rid- 
ing. The  patient  should  not  sit  on  warm  soft  cushions,  but  on  cane-seats 
or  those  covered  with  leather  or  horse-hair. 

Diet. — The  diet  should  be  mixed  in  character  and  in  part  consist  of  a 
considerable  variety  of  green  vegetables  and  raw,  ripe  and  cooked  fruits, 
to  regulate  the  bowels. 

It  should  suit  the  individual,  and  a  stout  full-blooded  person  must  be 
somewhat  limited  in  his  diet.  The  patient  should  not  take  three  large 
meals  at  long  intervals,  but  preferably  smaller  and  more  frequent  feedings. 

Alcoholic  beverages,  strong  coffee,  strong  tea,  highly  seasoned  dishes, 
cheese,  coarse  brown  bread,  peas,  corn,  and  baked  or  lima  beans  are  best 
avoided. 

String  beans,  spinach,  asparagus,  and  green  salads  aid  bowel  action. 
Potatoes,  rice,  beets,  and  cauliflower  may  be  allowed  in  small  quantity. 

'  The  Wassermann  or  Noguchi  reaction  should  be  tested. 


hemorrhoids;  prolapse  of  rectum;  fissure  787 

Raw  fruits,  such  as  apples,  pears,  prunes,  grapes,  oranges,  and  stewed 
fruits,  such  as  prunes,  baked  apples,  etc.,  are  of  value.  Soups  of  various 
kinds  are  allowed.  Hot  breads,  richly  spiced  foods,  and  rich  desserts 
should  be  avoided. 

Matzoon,  koumiss,  bacillac,  fermillac,  lactone-milk,  and  buttermilk 
often  have  an  excellent  effect  on  the  bowels.  They  can  be  taken  as  the 
extra  meals  midway  between  the  usual  meals.  A  few  crackers  or  zwie- 
back with  plenty  of  butter  can  be  given.  Some  recommend  water  only 
between  meals  and  interdict  much  of  that.  Unquestionably  a  certain 
amount  of  fluid  with  the  food  is  an  aid  to  digestion  and  bowel  action.  I 
have  seen  severe  cases  of  constipation  result  from  the  elimination  of  all 
fluids  at  meals. 

At  least  8  ounces  (250  c.c.)  of  iluid  in  the  form  of  broth,  soup,  cocoa, 
or  water  should  be  taken  at  each  meal.  On  rising,  the  administration  of 
a  glass  of  water  often  aids  bowel  action,  and  between  meals  an  equal 
amount  should  be  given,  or  matzoon  or  koumiss  substituted. 

Outdoor  exercise,  such  as  walking,  is  of  service.  It  should  not  be  car- 
ried to  the  point  of  fatigue,  and  is  contraindicated  during  acute  inflam- 
mation of  the  piles  or  if  hemorrhage  or  unpleasant  symptoms  result. 
,  Massage,  gymnastics,  and  Swedish  movements  are  of  value. 

Bowels. — Constipation  should  receive  appropriate  treatment.  Power- 
ful cathartics  should  be  avoided.  The  dietary  methods  mentioned  should 
be  carried  out.     The  patient  should  go  to  stool  daily  at  a  definite  hour. 

1  have  found  the  administration  of  olive  oil,  i  to  2  tablespoonfuls  (15.0- 
30.0)  t.i.d.  before  meals,  an  aid  to  bowel  action.     The  injection  of  i  to 

2  ounces  (30.0-60.0)  of  olive  oil  into  the  rectum  with  a  small  soft-rubber 
ear  syringe  just  before  having  or  attempting  to  have  a  movement  is  a 
valuable  procedure.     It  also  renders  the  passage  easier  and  less  painful. 

Aloes  should  be  avoided  in  hemorrhoid  cases. 

Among  our  simple  remedies  are  compound  liquorice  powder,  i  dram 
(4.0);  fluidextract  of  cascara  or  aromatic  fluidextract,  i  dram  (4.0);  ex- 
tract of  cascara,  i  to  5  grains  (0.06-0.3);  purgen  (phenolphthalein),  i>^  to 
5  grains  (0.1-0.3);  tincture  of  rhubarb,  i  dram  (4.0),  or  extract  of  rhei, 
4  grains  (0.25),  mineral  oil  and  regulin.  Other  remedies  are  described  in 
the  chapter  on  Constipation. 

Carlsbad,  Kissengen,  and  Saratoga  waters  are  o:  service,  especially 
at  the  springs. 

A  good  prescription  is  the  following: 

I^.  Ext.  cascara gr.  xv  (i.o); 

Ext.  belladonnae     \  ..•••/•      \      •»«■ 

-r.  .  .     \ aa  gr.  nj  (0.2). — M. 

Ext.  nucis  vomicasj 

Make  1 2  pills. 

Sig. — One  to  two  at  bedtime. 

Hygiene  of  the  Anus. — After  defecation,  cleansing  with  a  moist  sponge 
or  wet  cotton  is  less  irritating  than  paper. 

External  piles  should  be  protected  with  a  small  piece  of  cotton  moist- 
ened with  sweet  oil  or  covered  on  the  anal  side  with  vaselin,  boric  acid,  or 
zinc  ointment.     Cold  sitz-baths  and  cold  ablutions  to  the  rectum  are 


788  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

valuable.  An  external  douche  with  cold  water  is  excellent,  thus:  A  foun- 
tain syringe  is  filled  with  cold  water  at  about  6o°F.  and  several  ounces  of 
witch-hazel  added,  or  a  hot  douche  at  110°  to  ii5°F.  can  be  substituted. 
The  rectal  tip  is  placed  close  to  the  anus,  which  is  then  thoroughly  douched. 
This  is  especially  applicable  for  external  piles,  and  lessens  congestion  even 
when  they  are  internal. 

For  external  inflamed  piles  stronger  medicated  local  applications  can 
be  employed  than  with  internal  piles,  where  greater  absorption  occurs. 

External  Hemorrhoids. — With  inflamed  piles  absolute  rest  in  bed  or 
on  a  couch  should  be  enjoined.  A  small  ice-bag  or  gauze  wrung  out  in 
cold  solution  of  witch-hazel  and  water,  equal  parts,  or  of  lead-and-opium 
wash,  are  excellent  applications.  Some  prefer  the  application  of  warmth; 
cold  is  usually  more  efficacious. 

For  the  application  of  cold  to  relieve  congestion,  both  to  external  and 
internal  hemorrhoids,  the  simple  instruments  in  Figs.  316  and  317  are  of 
value. 

The  ice  tubes  for  hemorrhoids  are  made  in  a  nest  containing  several 
sizes,  in  appearance  like  a  very  small  test-tube  with  a  broad  flange,  to 


Fig.   316. — Kemp's  tube  (cooler)  for  hemorrhoids  or  prostate. 
Fig.  317. — Kemp's  ice  tube  for  hemorrhoids. 

prevent  slipping  into  the  bowel.  The  tube  is  filled  with  powdered  ice, 
corked,  well  lubricated,  and  inserted  into  the  anus.  They  are  made  of 
glass  or  metal,  the  latter  the  safer. 

The  prostatic  cooler  is  of  small  cahber — a  simple  closed  tube  with  a 
large  entering  and  small  return  attachment.  The  fountain  syringe  is 
attached  to  the  large  branch  and  a  soft  outflow  tube  to  the  smaller.  Very 
cold  (preferably)  or  hot  water  can  be  employed.  The  soft-rubber  rectal 
bag  (Fig.  318)  is  made  on  similar  principles,  but  is  more  bulky.  A  small 
rubber  condom,  with  two  catheters  tied  in,  one  for  the  entering  and  the 
other  for  the  outflow  current,  can  be  substituted  for  this  bag.  They  were 
reported  some  years  ago.^ 

In  addition,  one  can  attach  a  small  catheter  to  the  tip  of  the  fountain 
syringe  and,  inserting  the  soft  tube  about  i>^  inches,  thus  douche  the  in- 
ternal hemorrhoids.  The  current  should  be  slow,  the  patient  evacuating 
the  fluid  around  the  catheter  every  minute  or  so.  Hot  or  cold  normal 
saline  solution  with  witch-hazel,  i  ounce  (30.0)  to  the  pint  (500  c.c),  can 
be  employed.     The  old  Bodenhamer  recurrent  tip  or  the  flexible  or  hard- 

^  Manual  on  Enteroclysis,  Hypodermoclysis,  and  Infusion,  1900. 


hemorrhoids;  prolapse  of  rectum;  fissure 


789 


rubber  recurrent  tubes  (Kemp)  can  be  used,  introducing  them  only  about 
2  inches;  but  with  inflamed  piles  they  are  apt  to  cause  more  pain  than  the 
small  soft  catheter.  I  have  employed  a  recurrent  uterine  irrigator  for 
the  same  purpose. 


L 

Fig.   318 


-Kemp's  soft-rubber  rectal  bag,  used  as  a  cooler  for  hemorrhoids. 


I  have  found  the  following  prescriptions,  recommended  by  Samuel 
Gant,  of  value  for  the  relief  of  pain  and  inflammation  in  external  hemor- 
rhoids: 


I^.  Liq.  plumbi  subacet 3iv  15 

Tinct.  opii 3iiss  10 

Aq.  destil q.  s.  5iv  125 

Sig. — Apply  cold,  on  gauze. 

I^.  Ung.  stramonii 3iss  6 

Ung.  belladonnae 3iiss  10 

Ung.  acidi  tannici Sss  15 


.— M. 


.— M. 


or 


I^.  Morph.  sulph gr.  iij 

Cocainae  hydrochlor gr-  xij 

Vaselin 5  ij 

I^.  Cocainae  hydrochlor gr.  v 

Ext.  bellad.       1 

Ext.  opii  \ aa  3  ij 

Ext.  aconite      J 
Ext.  stramonii 

Glycerin 3  ss 

Sig. — Apply  on  cotton,  externally. 


60 


19s 
78 
.— M. 

325 


.— M. 


This  last  prescription  I  prefer  to  use  first  at  about  one-third  or  one-half 
strength.  It  should  be  employed  for  only  the  temporary  relief  of  severe 
pain  and  should  be  left  on  only  for  a  short  period,  about  fifteen  minutes. 

Cold  or,  at  times,  hot  injections,  and  opium  and  belladonna  supposi- 
tories are  excellent  for  tenesmus. 

For  internal  hemorrhoids,  when  prolapsed,  inflamed,  and  difficult  of 
reduction,  it  is  advisable  to  apply  cold,  such  as  ice-water  to  which  witch- 
hazel  has  been  added,  ice,  or  lead-and-opium  lotion  (cold),  for  a  brief 
period,  to  lessen  edema  and  inflammation. 

Local  application  of  adrenalin  (i  :  1000)  to  an  irreducible  pile  lessens 
congestion  and  aids  reduction. 

One  of  the  following  ointments  is  excellent  as  a  sedative: 


^.  Morph  sulph gr.  viij 

Hydrag.  chlor.  mit gr.  xij 

Vaselin 5  j 


30 


52 
78 

.— M. 
(Gant.) 


790 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


I^.  Ext.  opii 3ss  2J 

Cocainae  hydrochlor gr.  x  65 

Mentholi gr.  xx  i  30 

Ung.  zinci  oxidi 5  J  30'. — M. 

The  prolapsed  hemorrhoid  should  be  well  lubricated  before  the  physi- 
cian endeavors  to  push  it  up  with  the  finger.  Occasionally  an  anesthetic 
may  have  to  be  administered.  There  are  the  dangers  of  strangulation 
with  gangrene  and  sepsis,  from  an  unreduced  hemorrhoid. 

for  ulcerated  hemorrhoids  the  following  are  useful: 


I^.  Bismuth  subnit 3ij 

Hydrarg.  chlor.  mit 3ij 

Morph.  sulph gr.  iij 

Glycerin 3ij 

Vaselin 5  j 

Apply  with  a  pile  syringe  (Allingham). 


6 
19s 

.— M. 


Sig 


Sig. 


Cocainae  mur gr.  xij 

lodoformi 3i 

Ext.  opii 3ss 

Vaselin 5  j 

—Apply  with  a  pile  syringe  (Mathews). 


I78 


.— M. 


For  hemorrhage  the  following  are  of  service:  Rectal  injections  of  ice- 
water,  8  ounces  (250  c.c),  alone  or  with  tannic  acid,  15  grains  (i.o),  dissolved 
therein,  or  alum,  i  dram  (4.0),  or  witch-hazel,  equal  parts;  local  appli- 
cation of  ice-bags,  or  the  ice  tube. 

Several  ounces  of  Tremoliere's  solution — gelatin  (5  per  cent.)  with 
chlorid  of  calcium  (2  per  cent.) — can  be  injected  into  the  rectum.  It  was 
originally  used  as  a  local  styptic. 

If  the  bleeding  is  from  external  piles,  styptics  can  be  applied  in  oint- 
ment form;  if  from  internal  hemorrhoids,  the  ointment  can  be  inserted 
with  the  finger  or  applicator,  or  as  a  suppository. 

Among  such  useful  remedies  are  unguentum  acidi  tannici  and  unguen- 
tum  gallae. 

,         I^.  Unguentum  acidi  tannici 3iv 


Unguentum  stramon.      1  sa    *  • 

Unguentum  belladonnae  / ^ 

Ft.  ung. 

I^.  Suprarenal  ext gr.  v 

01.  theob gr.  xxx 

Ft.  suppos.  No.  1. 

i^.  Adrenalin  chlorid  (i  :  1000) TUx  (0.592) 

01.  theob q.  s. — M. 

One  suppository. 

I^.  Ichthyol 
Acidi  tannici 
Ext.  belladonnae  \  "  ..  ,/ 

Ext.stramon.      1 aa  gr.  ^^ 

Ext.  hamamelis gr.  x 

01.  theob .^ q.  s. 

Ft.  one  suppository.  (J.  P. 


16 

30 . — M. 

2  .— M. 


.aa  gr.  V 


3 

022 

|.— M. 
Tuttle.) 


An  ointment  or  suppository  containing  chrysarobin  has  been  advised 
for  the  treatment  of  hemorrhage  from  piles: 


hemorrhoids;  prolapse  of  rectum:  fissure 


791 


!l^.  Chrysarobin gr.  xv 

Ext.  belladonnae gr.  v 

Iodoform gr.  x 

Petrolati 3ss 

Ft.  unguentura. 

I^.  Chrysarobin gr.  ij 

Acidi  tannici gr.  iij 

lodoformi gr-  ij 

01.  theob gr.  xxx 

Ft.  one  suppository. 


IS 


3 
6 
.— M. 


13 
194 

13 


In  many  cases  of  hemorrhage  the  simpler  remedies  are  sufficient. 
Rarely  it  may  be  necessary  to  tampon  the  rectum.  This  can  be  performed 
by  slipping  in  a  piece  of  cheese-cloth  like  the  finger  of  a  glove,  in  effect  a 
bag,  with  the  outside  well  lubricated.  This  is  packed  with  cotton  tampons 
or  strips  of  gauze,  and  the  distended  bag  drawn  down  against  the  sphincter. 
It  can  be  done  in  emergency  without  an  anesthetic.  If  these  measures 
fail,  it  may  be  necessary  to  ligate  the  bleeding  artery  or,  if  this  be  impossi- 
ble, then  the  entire  hemorrhoid. 

Radical  Treatment. — Dilatation  of  the  Sphincters. — By  means  of  this 
the  spasm  of  the  sphincter  is  stopped,  the  pressure  on  the  blood-vessels 


Fig.  319. — Robert's  dilator. 

is  relieved,  and  the  bowels  act  more  easily.  It  will  frequently  be  of  benefit 
in  the  early  stages  of  hemorrhoids,  and  I  have  seen  it  relieve  severe  symp- 
toms in  advanced  cases,  especially  if  fissure  is  associated.  The  author  has 
noted  cases  in  which  several  years  after  dilatation  the  patient  has  claimed 
to  be  in  comfort,  with  no  recurrence.  As  a  palliative  the  procedure  is 
justifiable,  especially  if  fissure  is  present. 

Gradual  dilatation  by  the  use  of  specula  of  increasing  size  or  of  dilators 
can  be  carried  out.  The  procedure  takes  several  weeks  and  is  necessarily 
very  painful.  If  this  method  is  carried  out,  air  dilatation  with  Robert's 
dilator  (Fig.  319),  made  on  the  principle  of  Barnes'  cervical  dilator  bag, 
is  the  most  satisfactory.     The  hard-rubber  dilators  cause  more  pain. 

Rapid  and  complete  dilatation  under  anesthesia  is  the  best  method 
when  safe  for  the  patient.  With  the  aid  of  a  skilled  anesthetist  it  can  be 
satisfactorily  performed  under  nitrous  oxid.  Other  anesthetics  can  be 
employed.     The  thumbs  must  be  inserted  into  the  rectum  and  the  sphinc- 


792  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

ter  dilated  gradually,  both  laterally  and  anteroposteriorly.  All  spasm 
must  be  overcome  and  the  sphincter  thoroughly  relaxed.  Violence  must 
not  be  employed.  Formerly  an  opium  suppository,  i  grain  (0.065),  with 
belladonna,  3^  grain  (0.02),  was  inserted  and  the  bowels  kept  closed 
for  about  forty-eight  hours.  It  is  now  believed  preferable  not  to  use 
opium  but  as  soon  as  possible  to  have  the  patient  return  to  his  regular 
diet  to  which  fruit,  mineral  oil  or  mild  cathartic  may  be  added.  It  is 
best  to  insert  into  the  rectum  a  drain  tube  for  escape  of  gas  for  at  least 
twenty-four  to  forty-eight  hours  after  operation. 

Carbolic  Acid  Injection. — This  method  has  been  recommended  in  order 
to  produce  shrinking  of  the  piles  and  so  avoid  radical  operation.  It  should 
not  be  performed  if  the  hemorrhoids  are  inflamed. 

The  following  solutions  for  injection  have  been  recommended: 


I^.  Acid,  carbolic.  (Calvert's) Sij 

Acid,  salicylic 3ss 

Sod.  bibor 3i 

Glycerin  (sterile) q.  s.    5  J  30 — M. 

(J.  P.  Tuttle.) 

The  solution  should  be  syrupy  and  clear;  if  white,  it  is  imperfect. 

The  average  injection  into  a  hemorrhoid  is  5  minims  (0.296).  Not 
more  than  10  minims  (0.592)  should  be  injected  into  two  to  three  hemor- 
rhoids.    After  the  injection  insert  a  suppository  of — 


I^.  Opii  (pulv.) gr.  j 

Ext.  belladonnae gr.  J^ 

lodoformi gr.  ij 

01.  theob q.  s. 


065 
022 

13 
.— M. 


Carbolic  acid  and  glycerin,  equal  parts;  or  carbolic,  i;  glycerin,  3; 
water  (distilled),  3,  have  been  employed. 

Inject  3  to  5  drops  with  a  hypodermic  syringe  into  the  center  of  the 
pile.  Care  must  be  taken  that  none  of  the  solution  drops  from  the  needle 
and  cauterizes  the  mucous  membrane.  An  enema  is  first  given,  the  piles 
cleansed  and  dried,  and  then  anointed  with  iodoform  ointment  after  injec- 
tion with  carbolic. 

A  few  drops  of  a  i  per  cent,  cocain  solution  may  be  first  used  subcu- 
taneously  to  deaden  the  pain. 

It  is  preferable  to  inject  one  hemorrhoid  at  a  time.  Considerable  pain 
at  times  follows.  The  possible  dangers  are  ulcer,  abscess,  and  fistulae. 
There  is  some  danger  of  sepsis  and  cases  have  been  reported. 

Cauterization  with  Fuming  Nitric  Acid. — The  surrounding  parts  are 
covered  with  a  thick  layer  of  vaselin,  except  the  pile  that  is  to  be  treated. 
This  is  painted  with  the  nitric  acid  by  means  of  a  small  stick  or  glass  rod. 
Care  must  be  taken  that  the  acid  touches  no  other  spot.  The  pile  turns 
a  grayish-green  color  as  a  result.  Iodoform  ointment  or  vasehn  is  apphed 
and  the  hemorrhoid .  pushed  back  into  the  rectum.  Allingham  advises 
carbolic  acid  as  a  substitute  for  the  nitric  acid.  There  is  an  element  of 
danger  from  sepsis, in  this  method. 

Ligature  of  hemorrhoids  under  anesthesia  without  removal  and  then 
allowing  them  to  slough  of  has  been  employed.  The  method  is  not  to  be 
recommended  for  obvious  reasons. 


hemorrhoids;  prolapse  of  rectum;  fissure  793 

Crushing. — The  hemorrhoid  is  crushed  longitudinally  by  means  of  a 
special  instrument,  the  projecting  portion  cut  off,  and  pressure  kept  up  for 
about  a  minute.     This  technic  is  not  advised. 

Clamp  and  Cautery. — Each  pile  is  seized  with  a  volsellum  forceps  and 
drawn  well  down.  The  clamp  is  applied  to  embrace  its  base.  The  por- 
tion above  the  clamp  is  cut  off  with  scissors,  and  the  cautery  iron,  heated 
to  a  dull  red,  is  applied  to  the  stump  until  the  vessels  are  well  seared. 
Either  the  thermocautery  or  galvanocautery  can  be  employed.  Excellent 
results  have  been  secured  by  this  operation. 

Ligature  and  Extirpation  {Allingham's  Operation). — Incision  is'  per- 
formed at  the  base  of  each  pile  through  the  mucosa,  and  the  pedicle  dis- 
sected out.  This  is  ligatured  and  the  pile  cut  off  with  scissors.  Some 
operators  remove  every  alternate  hemorrhoid,  the  rest  usually  shrink- 
ing as  a  result  of  operation.  Others  incise  the  mucous  membrane  above 
the  base  of  the  pedicle  and  force  it  back  like  a  cuff.  After  ligature  and 
removal  of  the  pile,  the  cuff  of  mucosa  is  drawn  down  and  a  single  stitch 
taken.  This  last  method  is  to  be  recommended.  There  is  less  danger  of 
postoperative  hemorrhage,  and  healing  is  more  rapid. 

Extirpation  and  Suture  (Whitehead's  Operation). — The  mucous  mem- 
brane containing  the  hemorrhoids  is  dissected  out,  the  incision  frequently 
encircling  the  anus.  The  piles  are  removed,  and  the  mucosa,  being  loos- 
ened up,  is  drawn  down  and  attached  by  sutures  to  the  skin  at  the  anal 
margin.  Stricture  or  incontinence  of  feces  are  sequels  which  may  follow 
this  operation.  Subsequent  treatment  by  bougies  is  necessary  if  strictur- 
ing  be  feared,  or  if  it  occur. 

In  these  operations  anesthesia  is  necessary,  and  dilatation  of  the  sphinc- 
ter previous  to  removal  of  the  hemorrhoids. 

Former  operators  closed  the  bowels  for  twenty-four  to  forty-eight 
hours  after  operation  by  means  of  opium  suppositories,  though  Graser 
opens  the  bowels  at  once.  It  is  now  advised  to  return  to  normal  diet 
as  soon  as  possible,  adding  fruit,  green  vegetables  and  mineral  oil  or 
some  simple  laxative  if  required.  No  opium  is  given.  A  drain  tube  is 
inserted  for  twenty-four  hours  for  gas  escape.  Ten  grains  of  muriate  of 
quinine  in  water  gij  are  injected  through  the  rectal  drain  tube  which  is 
then  clamped  for  about  one  hour.  This  method  is  claimed  to  prevent 
pain.  It  is  repeated  in  six  hours.  The  temperature  of  the  fluid  should 
be  ioo°F. 

Gant's  Water  Infiltration  Method. — This  method,  devised  by  Samuel 
Gant,  is  of  special  value  in  cases  where  an  anesthetic  is  contraindicated 
or  when  the  patient  objects  to  its  employment.  With  a  large  hypodermic, 
sterile  water  is  injected  about  the  base  of  each  hemorrhoid  in  the  sub- 
mucosa,  producing  thorough  infiltration.  An  incision  is  then  made  around 
the  base  of  the  pile,  the  pedicle  dissected  out,  the  latter  ligated,  and  the  pile 
cut  off  with  scissors. 

Careful  prehminary  dilatation  of  the  sphincter  is  carried  out. 

Having  seen  this  operation  performed  by  its  originator  and  also  the 
ultimate  results,  I  can  recommend  it  as  excellent  in  selected  cases. 

Complications  of  Hemorrhoids. — Prolapse  of  the  Rectum. — Etiology. — 
Rectal  prolapse  is  a  fairly  frequent  complication  of  hemorrhoids,  though 


794  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

it  may  occur  alone.  It  may  involve  the  mucous  membrane  alone,  or  all 
the  coats  of  the  rectum  (procidentia  recti).  Among  other  causes  of  pro- 
lapse are  polypi,  vegetations,  tumors;  conditions  tending  to  weaken  the 
sphincters,  such  as  ulceration  or  operative  incisions,  spinal  paralysis,  or 
traumatism;  conditions  producing  muscular  spasm,  such  as  worms,  dysen- 
tery, phimosis,  cystitis,  calculus,  enlarged  prostate,  or  stricture  of  the 
urethra. 

In  some  cases  with  hemorrhoids,  the  prolapse  may  be  only  partial  as 
regards  the  circumference  of  the  rectum,  while  in  others  it  involves  the 
entire  circumference  and  there  is  a  scarlet  or  livid  mass  projecting  from 
the  anus.  An  internal  prolapse  of  the  rectum  may  occur,  in  which  the 
upper  part  descends  through  the  lower  part,  but  does  not  appear  outside 
the  anus.  It  is  probably  due  to  relaxation  of  the  ligaments  of  the  rectum. 
It  corresponds  rather  to  an  intussusception. 

Weakness  and  paralysis  of  the  sphincters  are  predisposing  factors. 

Prolapse  of  the  rectum  is  frequent  in  debilitated  children,  especially 
if  there  is  intestinal  catarrh  with  a  tendency  to  frequent  stools  accompanied 
by  straining.  Rectal  prolapse  occurs  in  elderly  people,  also  in  cases  of 
severe  constipation,  and  as  a  result  of  frequent  pregnancies. 

Symptoms. — With  moderate  prolapse,  during  the  act  of  defecation,  a 
protrusion  of  the  rectum  from  i  to  2  inches  long  appears  outside  the  anus. 
It  is  red  or  bluish  red  in  color  and  puckered  in  appearance,  covered  with 
some  mucus.  The  swelling  is  continuous,  with  the  skin  on  one  side  and 
with  the  mucous  membrane  on  the  other,  and  is  arranged  in  folds  which 
radiate  from  the  central  aperture  toward  the  circumference. 

In  advanced  cases  the  mass  resembles  a  tumor  with  a  star-like  opening 
at  its  center,  and  the  color  is  a  paler  red  or  bluish.  With  children  the  mass 
generally  protrudes  only  when  at  stool;  while  with  adults  it  comes  down 
more  readily  or  often  remains  constantly  down.  At  first  it  is  spontan- 
eously reducible,  later,  easily  replaced  by  slight  pressure,  and  finally  it 
may  become  very  difficult  or  nearly  impossible  of  reduction. 

It  often  become?  inflamed  or  ulcerated,  and  in  old  cases  incontinence 
of  feces  may  occur. 

At  first  there  is  no  or  little  pain,  but  after  a  time  it  may  become  quite 
severe. 

There  is  a  tendency  for  the  prolapse  to  increase  in  size.  If  inflamma- 
tion occur,  there  will  be  fever  and  constitutional  disturbances. 

As  a  rule,  there  is  no  marked  bleeding  from  the  prolapse  itself,  but  more 
of  an  oozing.     Hemorrhage  from  associated  hemorrhoids  may  occur. 

Diagnosis. — This  is  made  from  the  appearances  described.  If  opera- 
tion is  contemplated,  it  is  important  to  differentiate  between  prolapse  of 
the  mucosa  alone  or  of  the  rectum.  In  the  latter  event  the  peritoneum 
may  be  involved  and  the  intestines  be  found  in  the  prolapsed  portion. 

Prolapse  of  the  mucosa  is  not  as  firm  and  thick  to  the  feel,  the  folds  of 
the  mucous  membrane  radiate  from  the  orifice  to  the  circumference,  and 
the  opening  is  circular  and  patulous. 

With  prolapse  of  the  entire  wall  the  tumor  is  more  conic,  the  walls  are 
thick  and  firm,  the  orifice  is  slit-like.     When  the  mass  is  pressed  between 


hemorrhoids;  prolapse  of  rectum;  fissure  795 

the  fingers,  gurgling  of  gas  in  a  contained  loop  of  gut  may  sometimes  be 
heard  and  resonance  be  obtained  on  percussion. 

In  some  cases  where  there  is  much  inflammatory  thickening  it  is  diffi- 
cult to  differentiate.  In  following  out  treatment  this  possible  danger 
should  be  recognized  and  due  precaution  be  exercised. 

Internal  prolapse  is  more  difficult  to  recognize.  Digital  examination 
of  the  rectum  is  necessary.  First  keep  the  finger  close  to  the  anterior 
wall  until  it  passes  into  a  cul-de-sac.  Withdraw  it  slightly  and  examine 
the  center  of  the  mass  until  an  orifice  is  found  into  which  the  finger  or  a 
bougie  can  be  passed  for  some  inches  into  the  rectum. 

It  may  be  necessary  for  the  patient  to  bear  down  during  examina- 
tion. 

Treatment, — Predisposing  factors  should  be  eliminated,  hemorrhoids, 
polypi,  etc.,  removed.  Cleanliness  after  defecation  should  be  observed. 
The  prolapse  should  be  replaced  with  the  patient  preferably  in  the  knee- 
chest  position.  The  mass  should  be  thoroughly  lubricated  with  vaselin 
and  gently  pressed  into  the  rectum.  If  a  Considerable  portion  is  down,  a 
large  flexible  bougie  can  be  cautiously  passed  into  the  bowel,  pushing  be- 
fore it  the  upper  part  of  the  descended  gut,  and  pressure  (taxis)  should  be 
employed  evenly  on  the  other  surrounding  portions  with  the  fingers. 

When  the  prolapse  occurs  frequently,  a  rectal  supporter  should  be 
worn,  such  as  a  soft-rubber  ball  attached  to  the  anus  by  means  of  a  belt 
and  T-bandage.  A  supporter  can  be  improvised  by  employing  a  small 
roll  of  gauze  covered  with  oiled  silk  and  attaching  it  to  a  home-made 
T-bandage. 

With  children  palliative  treatment  is  more  successful.  The  cause  of 
the  difficulty  should  be  investigated  and  removed  if  possible,  such  as  a 
polypus.  The  general  health  should  be  built  up,  mild  laxatives  should 
be  administered,  and  the  diet  regulated  to  secure  easy  bowel  action  if  there 
is  constipation.  If  diarrhea  is  a  factor,  it  should  receive  treatment.  The 
child  should  be  instructed  not  to  strain  at  stool,  and  in  many  cases  it  is 
wise  to  have  him  defecate  in  the  knee-cJiest  posture  over  a  vessel  to  prevent 
prolapse  as  much  as  possible,  or  in  the  Sims  posture,  even  at  the  expense 
of  soiling  the  bedding  or  clothing,  which  can  be  easily  changed. 

If  prolapse  occurs,  it  should  be  washed  with  cold  water  or  weak  boric 
acid  solution  or  an  astringent  alum  solution,  i  dram  (4.0)  alum  to  8  ounces 
(250  c.c.)  water,  smeared  with  vaselin,  and  gently  returned  into  the  anus. 
A  weak  zinc  sulphate  solution  can  be  substituted.  After  this  the  patient 
should  remain  in  the  recumbent  position  for  about  half  an  hoiJr,  preferably 
lying  on  the  abdomen. 

Radical  measures  must  frequently  be  adopted.  Cauterization  of  the 
prolapsed  portion  with  fuming  nitric  acid  or  acid  nitrate  of  mercury,  as 
suggested  by  Allingham,  or  (preferably)  with  the  thermocautery  under 
anesthesia,  has  benefited  or  even  cured  cases.  After  cauterization  the 
prolapsed  part  should  be  lubricated  and  returned  into  the  anus.  Stric- 
tures are  occasionally  produced  by  this  procedure. 

Other  methods  have  proved  successful,  such  as  excision  of  elliptic  por- 
tions of  the  mucous  membrane  with  subsequent  suture;  extirpation  of  the 
prolapsed  portion;  revision  or  narrowing  of  the  caliber  of  the  rectum;  sus- 


796  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

pension  of  the  prolapsed  rectum  by  attaching  its  mesentery  to  the  abdom- 
inal wall;  or  suspension  of  the  lower  end  of  the  sigmoid  flexure. 

In  some  cases  Gant  infiltrates  the  mucosa  with  water  or  a  i  per  cent, 
eucain  solution  at  a  number  of  points  until  glassy  white  welts  are  formed. 
These  are  in  turn  seized,  pulled  down,  ligated,  and  left  to  slough  off.  The 
rectum  is  shortened  and  narrowed  as  healing  of  the  ulcerated  areas  takes 
place. 

Fissure  of  the  Anus. — This  condition  quite  frequently  occurs  with  hem- 
orrhoids. The  fissure  consists  of  an  oblong  tear  of  the  mucous  membrane 
of  the  anus,  which  gives  rise  to  pain  and  spasmodic  contraction  of  the 
sphincters.  Some  fissures  are  slight  abrasions  or  they  may  be  fairly  large 
and  deep.  The  edges  may  appear  healthy  or  be  inflamed  or  indurated. 
Those  of  longer  duration  present  the  appearance  of  an  ulcer.  In  fact, 
they  are  classified  as  irritable  ulcer. 

Anal  fissure  is  usually  caused  by  an  injury  or  tearing  of  the  mucosa  at 
the  edge  of  the  anus.  Excessive  straining  or  the  passage  of  dry  hard 
scybalae  are  factors.  It  is  moire  common  among  women.  The  fissure  may 
occur  in  any  location,  though  most  frequently  at  the  posterior  portion  of 
the  anus.  It  generally  lies  parallel  and  close  to  the  external  sphincter, 
though  it  may  be  higher  up  near  the  internal  sphincter  or  above  it. 

Symptoms. — Severe  pain  in  the  rectum  during  defecation  and  at  times 
tenesmus,  persisting  for  a  time  thereafter,  are  present.  The  pain  may  be 
very  severe  in  character,  so  that  the  patient  dreads  to  have  a  stool,  and 
increased  constipation  results. 

A  small  fissure  over  the  external  sphincter  usually  causes  greater  dis- 
turbance than  a  larger  one  higher  up.  There  may  be  reflex  irritation  of 
the  bladder  and  a  discharge  of  pus  and  blood  from  the  rectum.  From  the 
pain  and  suffering  the  nervous  system  may  become  affected. 

Diagnosis. — This  is  made  from  the  symptoms  and  by  local  examination. 
The  patient  should  lie  on  the  left  side  and  be  told  to  bear  down.  On  open- 
ing the  anus  with  the  finger  and  thumb,  a  fissure  (crack)  or  small  club- 
shaped  ulcer  can  frequently  be  seen.  It  may  be  red  and  inflamed  or,  if 
more  chronic,  of  a  gray  color  with  indurated  edges.  The  pain  may  be  so 
severe  that  before  local  examination  it  may  be  necessary  to  introduce  a 
suppository  of  cocain,  }i  grain  (0.016).  Rarely  an  anesthetic  may  be 
required. 

For  a  fissure  higher  up,  examination  with  the  speculum  may  be 
necessary. 

Treatm^M. — Hemorrhoids  or  polypi,  if  present,  should  be  removed. 
The  dilatation  of  the  sphincter  performed  during  this  operation  and  re- 
moval of  the  cause  of  the  fissure  usually  will  cure  the  case.  An  incision 
through  the  base  of  the  ulcer  can  be  made  at  the  same  operation  as  a 
precaution. 

Recent  fissures  are  at  times  cured  without  operation.  The  patient 
should  be  in  the  recumbent  position,  hot  lead-and-opium  lotion  can  be 
applied  externally  to  the  anus  if  there  is  much  pain,  as  heat  relieves  pain 
and  spasm. 

The  following  ointment  and  suppository  are  of  value  for  the  same 
purpose : 


hemorrhoids;  prolapse  of  rectum;  fissure  797 

I^.  Ext.  conii 5ij  81 

Olei  ricini 3iij  12 

Ung.  lanol q.  s.  3ij  60]. — M. 

Ft.  unguentum. 

I^.  Ext.  belladonnas gr-  ^■^  |o2 

Ext.  opii gr.  >^  03 

01.  theob gr.  XV  i{. — M. 

One  suppository. 

Locally,  the  fissure  can  be  touched  with  silver  nitrate  solution  (I  have 
used  the  pure  silver  nitrate  stick  twice  a  week),  varying  in  strength  from 
lo  to  30  grains  (0.6-2.0)  to  the  ounce  (30.0)  of  water  every  two  to  three 
days;  on  the  alternating  days  a  5  per  cent,  cocain  solution  can  be  carefully 
applied,  only  a  few  drops;  or  the  following  ointments  can  be  alternated 
with  the  silyer  application,  or  substituted  for  a  time: 

I^.  Ichthyol. gr.  xxx  2 { 

Lanolin Sij  8 

Petrolati q.  s.   5j  3o\. — M. 

Ft.  unguentum. 


or 


I^.  Hydrag.  chlor.  mit gr.  xv  i 

Pulv,  opii  ]  ..  ^ 

Ext.  belladonnae  / ^  * 

Petrolati 5ss  15 

Ft.  unguentum. 


3 
.— M. 


Gradual  dilatation  of  the  sphincter  without  anesthesia,  as  described 
under  Hemorrhoids,  especially  with  Robert's  dilator,  is  sometimes  em- 
ployed, but  this  procedure  is  painful. 

Dilatation  of  the  sphincter  under  anesthesia  is  often  found  curative  of 
obstinate  cases.     Nitrous  oxid  is  a  valuable  anesthetic  for  this  purpose. 

Some  recommend  infiltration  of  the  fissure  with  a  hypodermic  of  i 
per  cent,  cocain,  and  a  free  incision  through  its  base  to  the  sphincters. 
Gant  anesthetizes  the  tissues  posterior  to  the  rent  by  injecting  them  with 
sterile  water  or  a  0.125  per  cent,  eucain  solution  until  they  become  white. 
He  then  severs  the  sphincter  with  scissors  or  a  bistoury. 

An  incision  of  the  fissure  under  anesthesia,  combined  with  sphincter 
dilatation,  may  be  required. 

Proctitis. — If  proctitis  is  present  with  hemorrhoids,  it  must  receive 
appropriate  treatment,  as  described  under  the  section  on  that  subject. 

ABSCESS  OF  THE  RECTUM 

Abscesses  of  the  rectal  region  are  superficial  or  deep-seated,  and  the 
latter  are  subdivided  into  the  ischio-rectal  and  pelvic  abscess. 

Superficial  Abscess. — It  generally  originates  in  one  of  the  minute 
glands  near  the  anal  margin  and  may  result  from  traumatism,  from  infec- 
tion such  as  from  rectal  or  vaginal  discharges,  from  horseback  or  bicycle 
riding  and  from  suppuration  from  an  inflamed  external  hemorrhoid,  or 
follow  carbolic  injection  into  a  hemorrhoid,  may  result  from  a  gumma 
and  rarely  may  be  a  local  tubercular  process.     It  is  usually  small  and 


798  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

frequently  circumscribed.  It  may  break  spontaneously  through  the 
cutaneous  or  mucous  surface  at  the  anal  margin,  and  heal  without  the 
formation  of  fistula. 

The  best  treatment  for  these  cases  is  early  incision^  with  subsequent 
packing  of  the  cavity.    Local  anesthesia  can  usually  be  employed. 

Ischio-rectal  Abscess. — This  type  lies  below  the  levator  ani  muscle 
between  it  and  the  skin,  between  the  rectum  and  pelvic  wall.  It  may 
gravitate  or  burrow  toward  or  through  the  mucosa  into  the  rectum,  or 
upward  into  the  perineum  and  even  press  upon  the  prostate  and  urethra 
causing  retention  of  urine. 

Etiology. — Among  the  causes  are  traumatism  from  without  or  within, 
such  as  kicks,  falls,  wound  from  the  tip  of  an  injection  syringe,  puncture 
of  the  rectum  from  fish  bones  or  an  ingested  pin;  a  hemorrhoidal  opera- 
tion or  carbolic  injection  into  hemorrhoids;  ulceration  of  the  rectum 
in  connection  with  stricture,  rectal  ulcers,  proctitis  and  purely  a  local 
tubercular  process  may  be  responsible. 

Symptoms. — There  are  often  chills,  temperature,  pain  in  the  rectal 
region  and  if  the  process  gravitates  down  toward  or  starts  more  super- 
ficially, the  skin  will  be  red  and  edematous,  and  there  may  be  a  brawny 
swelling  near  the  anus,  spreading  a  considerable  distance  over  the  buttock. 
Difficulty  of  urination  and  even  retention  may  occur,  if  the  abscess  bur- 
rows toward  the  bladder.  When  the  inflammatory  process  is  deep-seated 
lying  near  the  mucosa  of  the  rectum,  there  may  be  no  cutaneous  redness 
or  swelling,  but  severe  pain  in  the  rectum,  particularly  on  defecation; 
rectal  examination  with  the  finger  will  detect  a  sensitive  area,  sometimes 
projecting  into  the  lumen  of  the  canal.  It  may  feel  boggy  or  even  give 
the  sensation  of  fluctuation.  There  are  also  throbbing,  and  heat  or  burn- 
ing in  the  rectum.  The  blood  shows  leukocytosis  and  increased  poly- 
nuclears.  The  patient  may  feel  quite  ill  and  have  gastro-intestinal  dis- 
turbances with  considerable  temperature,  or  the  inflammatory  process 
may  not  be  so  acute  and  the  case  attend  to  business  though  suffering  con- 
siderable pain  and  discomfort. 

Treatment. — This  is  surgical — consisting  of  a  free  incision  from  the 
skin  surface  with  drainage  and  packing.  All  pockets  should  be  opened 
up  and  sloughs  removed. 

Pelvic  Abscess. — This  t3^e  of  abscess  forms  above  the  levator  ani 
muscles,  lying  between  them  and  the  peritoneum  above.  It  may  burrow 
in  many  directions  in  the  pelvis  and  become  of  great  size;  may  discharge 
into  the  rectum  or  bladder,  or  point  in  the  groin,  loin,  or  thigh,  and  may 
cause  retention  of  urine  or  even  intestinal  obstruction  by  pressure. 

Etiology. — It  may  result  from  many  of  the  same  causes  as  the  ischio- 
rectal abscess,  such  as  damage  of  the  gut  by  a  rectal  bougie,  or  injury  by 
a  syringe  tip,  from  appendicitis,  from  disease  of  some  neighboring  organs 
such  as  inflammation  of  the  prostate,  extravasation  of  urine  from  rupture 
or  ulceration  of  the  urethra,  from  gonorrheal  infection,  tubo-ovarian  or 
uterine  infection  or  necrosis  of  some  adjacent  bone  of  the  pelvis  or  spine. 
With  bone  disease  the  abscess  may  be  of  the  cold  (tubercular)  variety. 

^  Occasionally  a  small  superficial  abscess  may  be  excised  and  an  attempt  be  made 
to  secure  primary  union  by  deep  suture. 


hemorrhoids;  prolapse  of  rectum;  fissure  799 

Psoas  abscess,  abscess  from  hip  disease,  perinephritis  and  periproctitis 
may  all  cause  pelvic  abscess. 

Symptoms. — In  acute  cases,  the  pelvic  pain  may  be  severe,  also  lumbar 
pain;  defecation  and  urination  may  be  painful  and  there  may  be  acute 
symptoms,  with  rise  of  temperature,  chills,  etc.  Diarrhea  may  occur  and 
the  patient  sink  into  the  so-called  "typhoid  state."  The  rectum  may  be 
found  extremely  tender  to  palpation.  Pus  may  escape  into  the  rectum 
or  bladder. 

In  the  chronic  type,  the  symptoms  may  not  be  acute  but  the  patient 
suffers  from  pain  and  discomfort;  there  is  a  low  grade  of  temperature 
with  leukocytosis,  etc.,  and  the  rectal  and  vaginal  examination  give  us 
information. 

Treatment. — This  consists  of  surgical  procedure — free  incision  and 
drainage  at  all  dependent  points. 

PRURITUS  ANI 

Irritation  and  itching  about  the  anus  is  designated  by  this  name.  It 
often  produces  great  discomfort.  The  irritation  is  usually  worse  when 
the  patient  is  in  a  warm  bed.  Scratching  aggravates  the  condition. 
There  may  be  no  morbid  appearances;  more  usually  the  skin  about  the 
anal  margin  is  red  and  thrown  into  deep  folds  which  may  appear  to  be 
drawn  within  the  anus.  On  separating  these  folds  the  sulci  may  appear 
eczematous.     The  skin  may  feel  harsh  and  rough  in  old  cases. 

Etiology. — This  may  be  local  or  general,  such  as  minute  thread  worms, 
pediculi,  hemorrhoids,  fissure,  proctitis,  or  a  gouty  diathesis. 

Treatment. — This  should  be  of  the  cause.  If  gouty  or  rheumatic, 
treat  these  conditions;  if  pediculi  or  thread  worms  appropriate  treatment 
is  indicated.  The  same  is  true  of  proctitis  or  other  causes.  Locally  lead 
and  opium  lotion,  witch-hazel  applications,  weak  carbolic  ointment, 
weak  mercurial  or  ichthyol  ointment,  resinol,  etc.  In  extreme  cases 
section  of  nerves  supplying  this  locality  has  been  suggested. 

FISTULA  IN  ANO 

Fistula  of  the  rectum  may  result  from  ulceration  or  perforation  of  the 
rectal  wall  from  within.  Thus  a  circumscribed  ulcer  may  perforate  the 
mucosa,  or  rupture  of  an  inflamed  hemorrhoid  may  be  responsible.  It 
is  usually  the  result  of  a  previous  abscess,  the  etiology  being  that  of  abscess 
as  already  described.     Fistulae  may  be  superficial  or  deep. 

They  are  divided  into  the  complete,  which  open  both  on  the  skin  and  into 
the  bowel;  external,  which  open  only  on  the  skin;  and  internal,  which  open 
only  within  the  bowel. 

Diagnosis. — When  there  is  an  external  opening — injection  through  it 
of  methylene  blue  solution  gr.  v  to  5i  or  same  amount  of  carmine  solu- 
tion results  if  there  is  also  an  internal  opening,  in  the  escape  of  colored 
solution  into  the  bowel.  The  external  opening  may  be  very  small,  a 
point  with  excess  of  moisture,  at  times  of  a  slightly  bluish  appearance. 
Frequently  the  cavity  which  it  drains  fills  up  at  times  so  we  get  an  ifi- 


8oO  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

duraied  area.  In  many  cases  one  can  detect  a  whip  cord  hardness  running 
toward  or  around  the  anus  under  the  skin.  Simple  internal  jfistula  is  more 
difficult  to  determine.  One  may  have  a  sensitive  point  on  digital  examina- 
tion which  may  be  due  to  ulcer  or  fissure.  Through  the  proctoscope  with 
a  fine  probe  one  may  determine  the  opening  of  the  fistula  in  most  cases. 
There  is  usually  some  discharge  at  this  point,  or  sometimes  a  small  ulcer 
which  when  gently  probed  will  admit  the  probe  to  a  fistulous  opening. 
Even  a  small  internal  fistula  may  cause  considerable  pain  of  a  burning 
character  which  may  last  several  hours  after  defecation.  Moreover,  the 
small  cavity  which  the  fistula  drains,  often  fills  up  so  that  one  can  feel  an 
indurated  area  or  a  tract  of  whip-cord  hardness  beneath  the  mucosa. 

When  probing  the  external  fistula,  whether  complete  or  incomplete, 
gentleness  should  be  eitiployed. 

Treatment. — The  writer  finds  the  prehminary  injection  of  a  methylene 
blue  solution,  gr.  v  to  5  i  water,  stains  the  fistulous  tracts  and  enables  one 
to  follow  them  out  with  ease  during  operation.  In  some  cases  with  ex- 
ternal fistula,  a  wide  incision  with  curetment  and  packing  or  iodoform  oil 
(lo  per  cent.)  injection  is  satisfactory.  With  complete  fistula  incision 
should  be  made  at  the  external  opening  and  the  tract  should  be  opened  up 
gradually  into  the  rectum.  The  sphincter  should  be  divided  at  right 
angles  and  the  edges  trimmed  so  ultimate  healing  is  not  interfered  with ; 
Gant  omits  packing.  When  there  is  an  internal  fistula  it  seems  preferable 
to  cut  down  externally  and  make  it  in  effect  a  complete  fistula,  also  divid- 
ing the  sphincter.  Occasionally  excision  of  a  small  fistula  may  be  prac- 
ticed with  deep  suture  of  the  fresh  surfaces. 


CHAPTER  XXXI 
APPENDICITIS 

(Synonyms. — Inflammation  of  the  Vermiform  Appendix;   Perityphlitis;  Appendicular 
Inflammation :  Scolecoiditis) 

Inflammatory  conditions  involving  the  right  iUac  region  have  been 
called  by  a  variety  of  names;  Iliac  phlegmon;  typhlitis  (inflammation  of 
the  cecum);  perityphlitis  (inflammation  of  the  covering  of  the  cecum); 
and  paratyphlitis  (inflammation  of  the  retroperitoneal  tissue  behind  the 
cecum).  Though  typhlitis  was  considered  to  be  the  cause  of  most  of  the 
inflammations  in  the  right  iliac  fossa,  modern  investigation  has  demon- 
strated that  appendicitis  is  the  chief  factor. 

Some  go  so  far  as  to  state  thet  even  stercoral  typhlitis  (an  inflamma- 
tion due  to  fecal  accumulation)  does  not  exist.  This  is  an  error,  as  C.  A. 
Mc Williams,^  though  admitting  it  to  be  rare,  shows  that  an  acute  or  chronic 
primary  typhlitis  may  occur  independently  of  appendicitis,  dysentery, 
tuberculosis,  actinomycosis,  or  cancer;  and  that  it  may  be  either  idiopathic 
in  origin  or  due  to  coprostasis. 

Autopsy  reports  and  findings  at  operations  have  confirmed  this,  "a 
typhlitis"  with  the  formation  of  perityphlitic  abscess  or  general  peritonitis, 
while  the  appendix  remains  normal.  Howard  Kelly  has  reported  14  cases 
presenting  primary  lesions  in  the  cecum,  the  appendix  being  normal. 

Over  90  per  cent,  of  inflammations  are  due  to  the  appendix;  the  rest 
to  the  cecum. 

The  symptoms  of  typhlitis  are  usually  indistinguishable  from  those 
of  appendicitis  and  the  indications  for  operation  are  the  same.  The 
literature  on  appendicitis  is  enormous,  and  I  shall  only  mention  the  names 
of  a  few  of  those  specially  identified  with  the  operative  technic  and  investi- 
gation of  appendicitis,  namely:  Reginald  Fitz,  Richardson,  Sands,  Mc- 
Burney,  Bryant,  Bull,  Weir,  Fowler,  Hartley,  Mayo,  Dawbarn,  R.  T. 
Morris,  Wyeth,  Blake,  Brewer,  Hotchkiss,  Deaver,  and  Howard  Kelly. 

Position  of  the  Appendix. — It  takes  its  origin  generally  from  the  pos- 
terior and  median  surface  of  the  cecum,  corresponding  to  McBurney's 
point  (ij^^  inches  from  the  anterosuperior  spine  of  the  ileum),  on  a  line 
drawn  from  the  spine  to  the  umbilicus.  The  average  length  is  from  3  to 
5  inches,  but  it  may  vary  markedly.  The  statistics  as  to  its  direction  are 
quite  variable.  It  may  point  downward  and  inward,  downward  behind 
the  cecum,  or  upward,  upward  and  inward,  transversely  inward,  or  out- 
ward. In  many  cases  the  appendix  is  quite  long,  and  the  position  and 
length  thus  explain  the  variable  locations  of  adhesions  or  abscess.  It  may, 
therefore,  come  in  contact  with  the  male  bladder  or  rectum,  with  the  uterus 
or  right  tube  and  ovary,  or  even  the  left  tube,  or  with  the  small  intestine, 
or  it  may  pass  up  as  high  as  the  liver  or  right  kidney,  even  to  the  left  rectus, 
and  close  to  the  spleen.  It  has  been  found  behind  the  peritoneum  with 
no  peritoneal  covering.  Bryant  has  reported  it  outside  the  peritoneal 
^Ann.  of  Surg.,  June,  1907. 
51  801 


802  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

cavity  in  three  cases.  It  has  been  found  quite  frequently  in  hernial  sacs,  and 
on  several  occasions  in  the  scrotum.  It  often  hangs  free  in  the  abdominal 
cavity.  In  a  few  instances  intussusception  of  the  appendix  into  the  cecum 
has  been  reported,  the  appendix  being  apparently  absent,  yet  the  patient 
suflfering  from  symptoms.  These  are  described  under  Intussusception  as 
Intussusception  of  the  Appendix.  Moreover,  the  appendix  may  be  be- 
neath the  serous  covering  of  the  cecum,  so  that  it  cannot  be  determined 
by  palpation.  An  incision  through  the  serosa  will  reveal  it.  This  condi- 
tion undoubtedly  accounts  for  the  so-called  congenital  absence  of  the 
appendix. 

Peculiarities  of  the  Appendix. — The  lumen  of  the  canal  is  extremely 
narrow;  the  organ  is  bottle  shaped,  the  narrowest  part  being  near  the  en- 
trance into  the  cecum.  Gerlach's  valve,  a  reduplication  of  the  mucous 
membrane  of  the  appendix  near  its  origin  from  the  cecum,  makes  the 
entrance  of  material  more  difficult,  and  also  its  exit.  The  circular  muscu- 
lar fibers  are  somewhat  scanty.  These  factors  tend  to  produce  stagnation 
and  predispose  to  infection. 

There  are  many  lymph-follicles  (adenoid  tissue)  in  the  appendix, 
which  usually  persist  up  to  the  age  of  about  thirty  and  then  begin  to  retro- 
grade, so  that  infection  is  easy,  as  in  the  tonsils.  In  many  cases  the  ap- 
pendix is  completely  surrounded  with  peritoneum,  in  some  it  is  only  par- 
tially covered,  and  the  uncovered  portion  is  in  direct  contact  with  the 
retroperitoneal  connective  tissue,  which  readily  accounts  for  the  so-called 
perityphlitic  abscess.  The  appendix  has  a  mesentery  of  its  own,  as  a 
rule,  the  meso-appendix,  but  it  is  not  constantly  present.  It  rarely  reaches 
.up  to  the  tip,  but  usually  only  one-half  to  two-thirds  of  the  distance.  It 
is  believed  to  have  some  influence  on  the  shape  of  the  appendix,  as  when 
it  is  relatively  short  the  latter  may  be  bent.  Crile,^  in  an  analysis  of  looo 
cases  of  appendicitis,  found  that  in  a  large  percentage  there  was  a  short 
meso-appendix,  causing  fixation  of  the  proximal  part  and  leaving  the  distal 
end  free,  which  tended  to  cause  the  appendix  to  fold  on  itself  and  interfered 
with  the  circulation  (an  anatomic  angulation). 

The  blood-supply  of  the  appendix  is  quite  scanty.  The  vessels  (the 
appendicular  and  a  few  cecal  branches)  Fowler  believes  to  be  functionally 
nearly  end  arteries,  the  most  abundant  being  from  the  vessels  (the  appen- 
dicular) in  the  meso-appendix,  so  that  the  vascular  supply  of  the  tip  of 
the  organ  is  poor. 

In  females,  Clado^  holds  that  there  is  a  third  source  of  blood-supply 
from  a  vessel  passing  through  the  appendiculo-ovarian  ligament  (a  fold 
of  peritoneum  passing  from  the  meso-appendix  to  the  broad  ligament), 
and  this  possibly  explains  why  appendicitis  is  less  common  in  women,  on 
account  of  the  superior  vascular  supply.  Fowler  holds  that  the  blood- 
vessels may  be  primarily  affected.  Misplacement  and  malformation  of 
the  appendix  may  also  have  an  influence.  The  pecuhar  anatomic  con- 
formation of  the  appendix  may  predispose  to  infection. 

Etiology. — The  chief  cause  of  appendicitis  is  bacterial  invasion,  the 
most  common  of  which  present  is  the  Bacterium  coli  commune.     As  a 

1  Ohio  State  Med.  Jour.,  June,  1907. 

*Compt.  Rend.  Soc.  Biol.,  1897,  vol.  iv,  p.  133. 


APPENDICITIS  803 

rule,  the  infection  is  a  mixed  one,  streptococci  being  frequently  associated. 
The  dependence  on  tube  cultures  alone  is  somewhat  inaccurate,  since  the 
Bacillus  coli  readily  overgrows  and  destroys  less  vigorous  organisms. 
Smears  should  be  taken  in  addition.  Careful  plate  cultures  should  be 
made  at  the  time  of  operation  and  also  cultures  under  anerobic  conditions. 
The  swab  should  always  be  brushed  against  the  intestinal  walls  and  not 
simply  dipped  in  the  exudate.  In  Kelly's  400  cases  the  Bacillus  coli  was 
present  in  92  per  cent.     The  proteus  vulgaris  has  been  present. 

The  Diplococcus  pneumoniae,  staphylococci,  the  anaerobes,  and  the 
influenza  bacillus  have  been  found.  These  are  the  most  frequent  varie- 
ties, and  are  found  both  in  the  appendix,  appendical  abscess,  and  in  the 
general  peritoneum  (fluid  of  the)  if  peritonitis  is  present.  In  isolated  cases, 
appendicitis  is  believed  by  some  to  be  a  local  expression  of  a  general  infec- 
tion, as  associated  with  scarlatina,  measles,  rotheln,  small-pox,  chicken- 
pox,  parotitis,  influenza,  and  acute  articular  rheumatism.  It  has  ac- 
companied suppurative  tonsillitis. 

Typhoid,  dysentery,  and,  more  rarely,  tuberculosis  may  be  causes. 
Actinomycosis  has  also  been  demonstrated  to  have  produced  it. 

Traumatism^  or  injury  from  lifting  have  been  given  as  causes,  but 
probably,  if  appendicitis  occurs  as  a  sequel,  the  organ  was  previously  dis- 
eased or  damaged,  or  the  symptoms  might  be  due  to  a  circumscribed 
traumatic  peritonitis. 

Constipation  as  a  factor  in  the  production  of  appendicitis  is  a  question 
of  dispute.  Fitz  and  Fowler  believed  that  in  the  majority  of  patients 
the  bowels  acted  regularly  previous  to  the  attack,  and  Riegel  holds  that 
constipation  and  diarrhea  have  no  bearing  on  the  subject.  Though 
unquestionably  many  patients  suffering  from  constipation  never  suffer 
from  appendicitis,  there  is  one  type  of  case  in  which  it  may  be  a  factor, 
namely,  patients  in  whom  there  is  a  tendency  to  fecal  accumulation  in  the 
caput  coli  and  lower  ileum,  with  resulting  appendix  symptoms,  probably 
from  circulatory  interference,  pressure,  blocking  of  the  appendix  opening, 
and  catarrh  secondary  to  a  slight  catarrh  of  the  cecum.  I  have  seen  sev- 
eral such  cases  in  which  there  were  the  typic  symptoms,  which  rapidly 
subsided  after  thorough  bowel  irrigation,  ice-bag,  and  later  cathartics,  and 
subsequent  treatment  of  the  constipation,  with  no  subsequent  attacks 
during  eight  or  ten  years'  observation.  To  this  same  class  belong  the 
rare  type  of  typhlitis  due  to  stercoral  ulcer  to  which  Mc Williams  refers. 

Dietetic  indiscretions,  in  so  far  as  they  are  productive  of  intestinal 
putrefaction  or  fermentation  with  increased  bacterial  activity,  might  be 
a  factor  in  producing  an  acute  attack  in  an  appendix  already  damaged. 
Kelly  and  Deaver  hold  that  disturbances  of  digestion  have  an  important 
influence  in  determining  an  attack  of  acute  appendicitis.  Intestinal 
catarrh,  involving  the  caput  coli,  in  my  own  experience  has  been  the 
direct  cause  of  the  catarrhal  type  of  appendicitis. 

Entozoa,  such  as  the  Trichocephalus  dispar,  Oxyuris  vermicularis, 
Ascaris  lumbricoides,  tapeworm,  and  bilharzia,  have  been  factors  in  the 
production  of  appendicitis.  An  interesting  case  of  perforation  of  the 
appendix  by  a  round  worm,^  with  appendical  abscess  resulting,  has  been 

*  Deaver,  N.  Y.  Med.  Jour.,  June  15,  1907. 
^'Jour.  Amer.  Med.  Assoc,  Sept.  25,  1909. 


8o4  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

reported.  Metchnikoflf,  in  1901,  first  emphasized  the  importance  of  in- 
testinal parasites  as  the  exciting  cause  of  appendicitis,  and  reported  three 
cases  in  which  the  feces  contained  ova  of  the  ascaris  and  trichocephalus. 
They  all  recovered  without  operation  after  a  vermifuge.  Cecil  and  Buckley 
report  five  cases  of  appendicitis  produced  by  the  Oxyuris  vermicularis  at  a 
meeting  of  the  New  York  Academy  of  Medicine,  May  17,  1910,  Movable 
kidney,  through  pressure  on  the  mesenteric  vein,  has  been  given  as  a 
frequent  cause  by  Edebohls.  This  condition  is  associated  with  splanch- 
noptosis, and  the  circulatory  changes  from  malposition  of  the  viscera^  are 
more  probably  factors.  They  occur  most  frequently  with  women,  yet 
appendicitis  is  less  frequent  in  the  female. 

Foreign  bodies  entering  the  appendix,  such  as  grape-seeds,  cherry-stones, 
pits,  pins,  buttons,  hairs,  shot,  gall-stones,  etc.,  are  rare  causes  of  appendicitis. 

Fecal  concretions  are  found  frequently  and  have  been  mistaken  for 
foreign  bodies.  Probably  normally  soft  fecal  matter  enters  and  is  ex- 
pelled from  the  appendix.  .  The  fecal  concretions  are  generally  hard  in 
character  from  absorption  of  water  and  are  thickened  by  mucus.  C.  B. 
Lockwood  has  demonstrated  that  in  many  cases  they  consist  of  an  in- 
spissated mass  of  bacteria.  It  is  easy  to  understand  how  such  concretions, 
if  of  large  size,  can  exert  pressure  and  even  be  productive  of  ulceration, 
especially  if  there  be  any  abnormal  condition  in  the  appendix.  They 
have  been  found  in  one-third  to  nearly  one-half  of  the  cases. 

Small  concretions  might  remain  in  an  appendix  without  harm.  They 
generally  lie  near  the  end  (tip). 

Diverticula  of  the  appendix  may  be  the  cause  of  appendicitis.  Some 
interesting  observations  have  been  made  by  W.  C.  MacCarty-  as  to  the 
relations  of  carcinoma  to  appendicitis. 

1.  In  a  series  of  2000  specimens,  0.6  per  cent.,  or  about  i  in  every  175 
appendices  removed  at  operation  are  malignant. 

2.  In  a  series  of  5000  specimens,  0.44  per  cent.,  or  about  i  in  every  225 
appendices  removed  at  operation  are  malignant. 

3.  In  a  series  of  2000  specimens,  2.2  per  cent.,  or  about  i  in  every  40 
partially  or  completely  obliterated  appendices  are  malignant. 

4.  In  a  series  of  5000  specimens,  1.6  per  cent.,  or  about  i  in  every  53 
partially  or  completely  obliterated  appendices  are  malignant. 

5.  Carcinoma  of  the  appendix  may  occur  as  early  as  five  years  of  age 
and  as  late  as  eighty  years  of  age. 

6.  Of  the  carcinomata  of  the  appendix  found  in  this  series,  77  per  cent. 
were  not  capable  of  being  diagnosed  from  the  gross  external  appearance. 

Harte  has  only  collected  five  cases  of  primary  sarcoma  of  the 
appendix,  and  Powers^  reports  one  case  in  a  girl  of  seventeen  years. 

Williams^  believes  intestinal  lithiasis  depending  on  the  calcium  soaps 
from  fats  in  food,  has  some  bearing  on  the  incidence  of  appendicitis. 

^  With  enteroptosis,  the  appendix  may  be  tender  in  some  cases,  and  relief  be  afforded 
by  proper  mechanical  support  and  forced  feeding  (curing  the  ptosis;;  others  require 
operation. 

''Jour.  Amer.  Med.  Assoc,  Aug.  6,  1910. 

'N.  Y.  Med.  Jour.,  Jan.  7,  191 1. 

*Brit.  Med.  Jour.,  Dec.  31,  1910. 


APPENDICITIS  805 

Right  tubo-ovarian  inflammation  may  be  a  factor  in  the  production 
of  appendicitis. 

Age. — Appendicitis  seems  most  frequent  between  ten  and  thirty  years, 
Fitz  stating  that  50  per  cent,  occur  before  the  twentieth  year,  and  Einhorn 
60  per  cent,  between  sixteen  and  thirty  years.  It  has  been  reported  as 
early  as  the  seventh  week,  but  rarely  before  the  third  year.^  At  the  Pres- 
byterian Hospital,  New  York,  33.9  per  cent,  occurred  before  twenty  years, 
and  68.9  per  cent,  before  thirty  years. 

Sex. — Men  suffer  from  appendicitis  much  more  frequently  than  women 
(from  2  to  3  or  more  to  i).  Johnson  states  4  to  i;  Deaver  64.2  per  cent, 
in  males.     At  the  Presbyterian  Hospital  the  percentage  was  nearly  equal. ^ 

Varieties. — I  will  describe  both  the  pathologic  and  clinical  types  of 
appendicitis. 

From  a  pathologic  standpoint,  the  following  seems  the  best  classifica- 
tion: 

1.  Acute  catarrhal  appendicitis,  in  which  the  mucous  membrane  is 
involved,  being  swollen  and  edematous,  the  submucosa  is  injected  with 
excessive  secretion  of  mucus  or  mucopus. 

This  type  is  mild,  and  the  appendix  drains  into  the  cecum  with  perfect 
recovery  (endo-appendicitis.  Fowler). 

2.  Acute  Disuse  Appendicitis. — There  is  inflammation  of  the  mucosa 
and  thickening  of  the  entire  organ,  which  is  rigid,  tense,  and  infiltrated. 
By  some  it  is  classified  as  catarrhal,  but  this  is  incorrect. 

The  peritoneal  surface  is  hyperemic.  There  may  be  erosions  or  small 
ulcers  and  a  fecal  concretion.  There  may  be  mucus  or  mucopurulent 
material  in  the  lumen,  or  in  some  cases  it  may  be  narrowed  or  obliterated. 

This  type  sometimes  hangs  free  in  the  abdomen,  but  more  generally  is 
adherent  to  the  adjacent  peritoneal  structures,  and  is  characterized  by 
the  surgeons  clinically  as  acute  nonsuppurative  appendicitis.  It  may 
resolve  without  operation. 

On  the  other  hand,  this  pathologic  type  may  be  productive  of  abscess  or 
perforation,  when  it  would  be  placed  under  a  different  class  by  the  surgeons. 

3.  Purulent  or  Suppurative  Appendicitis. — This  is  a  more  advanced 
stage  than  the  former.  There  is  a  definite  pus-sac  formed  by  the  appen- 
dix. This  type  may  also  perforate  and  cause  local  abscess  or  general 
peritonitis. 

4.  Gangrenous  Appendicitis. — This  is  characterized  by  necrosis,  local 
or  general.     The  tip  is  most  frequently  involved  or  the  entire  organ. 

5.  Chronic  Appendicitis. — This  may  follow  the  acute,  or  the  process 
may  be  slow  and  gradual  from  its  incipiency.  In  some  cases  the  changes 
have  been  found  to  be  very  slight,  merely  the  evidence  of  a  chronic  catarrh 
of  the  mucosa,  probably  an  extension  from  a  chronic  catarrh  of  the  cecum. 
At  times  stenosis  is  present. 

On  the  other  hand,  the  organ  has  been  found  firm,  slightly  enlarged 
and  thickened,  the  mucosa  thickened,  and  the  lumen  narrowed.  In  some 
cases  there  may  be  a  stenosis,  with  formation  of  a  cyst.     In  others  there 

^  Appendicitis  may  apparently  occur  in  several  members  of  one  family.  Horace 
Baldwm  reports  to  me  three  children  operated  for  chronic  appendicitis  for  example. 

-  McWilliams,  Analysis  of  141 7  Operations  upon  the  Appendix,  N.  Y.  State  Jour, 
of  Med.,  March,  1910. 


8o6  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

are  concretions  or  erosions,  or  partial  obliteration  of  the  lumen;  or  the 
appendix  may  become  converted  into  a  cord-like  structure,  embedded  in 
a  mass  of  thick  peritoneal  adhesions. 

6.  Obliteraiive  Appendicitis. — A  gradual  involution  process  occurs  in 
many  individuals.  The  tube  is  thickened,  the  peritoneal  surface  smooth; 
the  distal  portion  of  the  lumen  may  be  entirely  obliterated,  and  the  organ 
becomes  sclerotic  and  shrunken.  Ribbert  found  these  changes  in  more 
than  50  per  cent,  of  subjects  over  sixty  years  of  age.  Normal  involution 
seems  to  present  no  symptoms. 

On  the  other  hand,  W.  C.  MacCarty,^  from  his  observations  at  St. 
Mary's  Hospital,  Rochester,  Minn.,  concludes  as  follows: 

1.  Of  all  appendices  removed  at  operation  23.5  per  cent,  are  partially 
or  completely  obliterated. 

2.  The  shortest  duration  of  the  process  of  obliteration  when  it  is  con- 
tinuous is  less  than  ten  years. 

3.  The  process  may  be  complete  at  ten  years  of  age. 

4.  Obliteration  does  not  occur  as  a  physiologic  involutionary  process, 
but  is  dependent  on  a  definite  inflammatory  reaction. 

5.  There  seemed  to  be  a  large  percentage  of  appendices  (52  per  cent.), 
with  partially  or  completely  obliterated  lumina,  in  association  with  in- 
flammatory conditions  of  the  gall-bladder  (cholecystitis  and  cholelithiasis). 
This  partial  obliteration  of  the  lumen  occurred  more  frequently  in  females, 
which  may  be  possible  evidence  that  this  inflammatory  process  in  the 
appendix  causes  disturbances  in  the  bile  passages  directly  or  indirectly, 
and  may  have  some  relation  to  the  fact  that  cholecystitis  is  more  frequent 
in  females  than  in  males. 

MacCarty^  and  McGrath  in  a  subsequent  article  show  that  total  ob- 
literation of  the  appendix  occurs  on  the  average  at  34.6  years,  while  that 
of  the  tip  averages  at  29.8  years  of  age.  Carcinoma  of  the  appendix  oc- 
curred 22  times  out  of  5000  specimens,  or  in  0.44  per  cent,  of  cases.  In 
17  cases  diagnosis  by  the  surgeon  at  time  of  operation  was  impossible 
and  the  carcinomatous  condition  was  only,  revealed  by  the  microscope. 
On  section  there  is  an  orange-colored  area  in  the  obliterated  portion  of 
the  appendix.  They  hold  that  all  obliterated  appendices  should  be  re- 
moved and  sectioned.  Moreover,  they  found  that  obliterated  appendices 
may  become  acutely  inflamed  and  carcinoma  may  appear  at  any  age  in  an 
obliterated  appendix.  Diverticula  of  the  appendix  were  found  in  17  cases, 
and  of  these  56  per  cent,  occurred  in  acute  appendicitis,  and  in  women. 
They  conclude  that  all  obliterated  appendices  should  be  removed. 

From  a  clinical  standpoint  the  physician  will  find  several  types  of 
acute  and  chronic  appendicitis,  readily  deduced  from  the  pathologic 
classification. 

I .  A  cute  Simple  Catarrhal  A  ppendicitis  (Endo-appendicitis) . — A  catarrh 
of  the  mucosa  of  the  appendix.  This  is  of  mild  type  and  is  often  secondary 
to  a  colitis  or  to  fecal  impaction  in  the  cecum.  Unless  there  is  occlusion, 
the  inflammatory  products  usually  drain  out  (non-suppurative  type,  with 
complete  cure).     There  may  be  recurrent  attacks. 

^Jour.  Amer.  Med.  Assoc,  Aug.  6,  1910. 

*  Surgery,  Gynecology,  and  Obstetrics,  March.  1911. 


APPENDICITIS 


807 


2 .  A  cute  Nonsuppurative  A  ppendicitis  {Sometimes  Incorrectly  Character- 
ized as  Acute  Catarrhal). — The  description  is  that  of  the  Acute  Diffuse 
Appendicitis,  the  entire  organ  being  involved. 

There  is  fibrinous  exudation  agglutinating  the  appendix  to  neigh- 
boring structures,  and  the  meso-appendix  is  thickened  and  inflamed. 
There  may  be  kinking  or  torsion  of  the  organ,  stricturing,  or  even  oblit- 
eration, and  a  fecal  concretion  may  be  left  within  it. 

These  cases  often  escape  operation  and  may  not  have  a  recurrence, 
but  there  is  great  liability  of  the  latter.  On  the  other  hand,  ulceration 
with  perforation  may  occur. 

3.  Chronic  Appendicitis. — This  may  follow  the  acute,  or  the  process  be 
slow  and  gradual  from  the  start.     The 
chronic  catarrhal  cases  may  exhibit  but 
little  change,  or  the  appendix  may  be 


Fig.  320. — Symmetric  involution  of  ap- 
pendix (Morris). 


Fig. 


321. — Nodular  involution  of  ap- 
pendix (Morris). 


thickened,  the  mucosa  thick  and  hyperemic,  and  its  lumen  narrowed, 
obliterated,  or  strictured. 

A  fecal  concretion  may  remain  within  it.  It  may  present  adhesions. 
It  may  follow  an  acute  attack  or  be  chronic  from  the  onset. 

These  three  types  are  characterized  by  absence  of  perforation,  gangrene, 
or  abscess  formation;  though  type  2  may  progress  to  type  4,  with  result- 
ing abscess  or  perforation. 

4.  Acute  Suppurative  Appendicitis  {Formation  of  Abscess). — Of  this 
we  have  two  clinical  types,  the  pathologic  purulent  appendicitis  (the  appen- 
dix distended  with  pus),  on  the  verge  of  perforation,  or  an  inflamed  appen- 
dix enclosed  in  an  abscess-cavity  containing  a  varying  amount  of  foul 
pus.  The  walls  of  the  cavity  are  formed  by  adjacent  peritoneal  surfaces, 
coils  of  intestines,  cecum,  and  omentum  bound  together  by  adhesions. 

The  appendix  lying  in  the  abscess-cavity  is  congested  and  swollen, 


8o8  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

and  may  or  may  not  be  perforated  or  present  areas  of  gangrene.  It  may 
be  adjacent  to  the  cecum  or  intestines  or  reach  into  the  pelvis  to  the  blad- 
der or  tubes  and  ovaries.  Perforation,  when  present,  is  generally  near  the 
free  end  of  the  appendix. 

5.  Gangrenous  Appendicitis. — The  appendix  is  congested,  swollen, 
thick,  and  red,  with  gangrenous  areas  of  greenish-black  color  and  usually 
already  perforated.  It  is  marked  by  the  absence  of  protective  peritoneal 
adhesions. 

There  may  be  a  fatal  septic  peritonitis  before  perforation  of  the 
appendix.  Patches  of  fresh  fibrin  may  be  present  with  serous  or  bloody 
turbid  serum  in  the  peritoneal  cavity  or  adhesions  with  pus. 


Fig.  322. — Transverse   section   of   the   appendix,   showing   replacement  of  the   inner 
coats  by  connective  tissue  (Morris). 

The  condition  is  an  acute  gangrene  due  to  thrombosis  and  occlusion  of 
the  blood-vessels.  If  the  case  is  more  chronic,  some  plastic  peritonitis 
may  be  present. 

A  purulent  appendix,  an  acute  diffuse  appendicitis,  or  a  concretion 
may  ulcerate  through,  so  that  any  of  these  types — including  the  gangren- 
ous— may  be  classified  as  perforative  appendicitis. 

6.  Protective  Appendicitis,   or  Harmful   Involution   of  the   Appendix 

(Morris). — The  vermiform  appendix  normally  undergoes  an  involution 

process  with  replacement  of- the  lymphoid,  mucous,  and  submucous  coat 

by  connective  tissue.     R.  T.  Morris^  notes  that  the  nerve-filaments  per- 

1  Med.  Rec,  April  6,  1907;  ibid.,  Jan.  8,  1910. 


APPENDICITIS  809 

sist  longer  than  other  structures,  and  contraction  of  the  connective  tissue 
in  some  cases  irritates  these  nerve-filaments,  so  that  irritation  of  the 
ganglia  of  the  bowel  (Auerbach's  and  Meissner's  plexuses)  ensues  and 
causes  disturbances  in  the  nearby  intestines.  This  condition  he  char- 
acterizes as  ''fibroid  degeneration  of  the  appendix."^ 

The  appendix  is  at  no  time  the  seat  of  acute  or  chronic  infection,  and 
the  condition  is  characterized  by  intestinal  dyspepsia  and  other  definite 
symptoms  which  will  be  described  later.  The  involution  may  be  sym- 
metric or  nodular  (Figs.  320-322)  and  occurs  most  markedly  toward  the 
distal  extremity. 

R.  T.  Morris^  classifies  four  kinds  of  appendicitis. 

1.  Protective  Appendicitis. — An  irritative  lesion  without  infection. 

2.  Appendicitis  with  Intrinsic  Infection. 

3.  Syncongestive  Appendicitis. — An  irritative  lesion,  due  to  serous 
infiltrates  in  the  tissues  of  the  appendix  and  occurring  synchronously  with 
similar  congestion  of  neighboring  tissues.  For  example,  it  may  occur  with 
obstruction  of  the  lymph  and  blood  circulation  through  certain  diseases 
of  vital  organs  and  with  loose  right  kidney. 

4.  Appendicitis  with  Extrinsic  Infection. — An  infective  lesion  due  to 
bacterial  approach  from  other  structures  lying  outside  of  the  appendix, 
such  as  from  inflammation  of  the  uterine  adnexa. 

A.  V.  Mosckowitz  suggests  a  classification^  which  he  has  elaborated 
after  a  study  of  nearly  4000  cases  at  the  Mt.  Sinai  Hospital.     It  embraces 
both  the  pathologic  and  clinical  aspects. 
I.  Catarrhal  inflammations. 

(a)  Acute  catarrhal  appendicitis. 
(jb)   Chronic  catarrhal  appendicitis. 
{c)    Acute  catarrhal  appendicitis  with  abscess. 
{d)  Appendicular  abscess. 
II.  Destructive  inflammations. 

(a)  Acute  gangrenous  appendicitis. 
{h)  Acute  gangrenous  appendicitis  with  abscess, 
(c)   Acute  gangrenous  perforative  appendicitis. 
{d)  Acute  gangrenous  perforative  appendicitis  with  abscess. 
{e)  Acute  gangrenous  or  perforative  appendicitis  with  gangrene  of 
cecum. 

III.  Retention  cysts. 

(a)  Hydrops  of  appendix  (mucoid  contents). 

{h)  Empyema  of  appendix. 

(c)   Empyema  of  gangrenous  appendix. 

IV.  In  combination  with  blood  infections. 

(a)  Acute  gangrenous  or  perforative  appendicitis  with  thrombosis  of 
mesentery. 

{h)  Acute  gangrenous  or  perforative  appendicitis  with  portal  pyle- 
phlebitis. 

*  Amer.  Jour,  of  Surg.,  October,  iqoq. 

*  Protective  Appendicitis,  p.  97.  Dawn  of  the  Fourth  Era  in  Surgery  (R.  T.  Morris), 
W.  B.  Saunders  Co.,  1910. 

^  Amer.  Jour,  of  Surg.,  Sept.,  1910. 


8lO  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

V.  In  combination  with  peritonitis. 

(a)  Dry  or  fibrinous  peritonitis. 

(b)  Serous  peritonitis. 

(c)  Seropurulent  peritonitis.  • 

(d)  Purulent  peritonitis. 

(e)  Appendicular  abscess  with  purulent  peritonitis. 

VI.  Specific  inflammations. 

(a)  Tuberculosis. 

(b)  Actinomycosis,  etc. 

VII.  New  growths. 

(a)  Carcinoma. 

(b)  Sarcoma. 

(c)  Fibroma. 

(d)  Diverticula,  etc. 

This  table  the  writer  believes  of  chief  value  as  an  index  to  the  possible 
conditions  that  may  be  found  at  operation. 

Symptoms  of  Acute  Appendicitis. — The  symptoms  of  acute  appendi- 
citis are  modified  by  the  character  of  the  lesion,  whether  it  is  a  simple 
catarrh,  an  appendicitis  with  the  production  of  adhesions,  a  pus-cavity, 
or  of  the  acute  gangrenous  type. 

In  general  the  cardinal  symptoms  of  acute  appendicitis  are  as  follows: 

1.  Sudden  pain  in  the  abdomen  in  the  right  iliac  region,  or  at  times 
first  epigastric  or  umbilical,  which  soon  or  gradually  localizes  in  the  right 
iliac  fossa.  Pains  are  continuous,  increasing,  or  there  are  only  exacerba- 
tions of  pain.     More  rarely  general  abdominal  pain  is  at  first  present. 

2.  Tenderness  or  pain  on  pressure  in  the  right  iliac  region  at  Mc- 
Burney's  point.  Often  there  is  an  area  of  resistance  due  to  tumor  or  to 
muscular  rigidity.  Localized  rigidity  is  frequently  our  main  guide  in 
children.  The  symptoms  are  often  misleading  in  infants.  Deaver^  re- 
ports 300  cases. 

Moreover,  we  must  remember  that  in  children  the  abdomens  are 
small  and  their  appendices  are  relatively  long,  so  that  sensitiveness  at  a 
distance  from  McBurney's  point  is  more  common  than  in  adults. 

3.  Fever  of  moderate  or  severe  type. 

4.  Gastro-intestinal  disturbances  may  be  present,  such  as  nausea  or 
vomiting,  and  frequently  constipation. 

5.  In  the  septic  gangrenous  type  I  have,  in  a  fairly  large  percentage  of 
cases,  observed  a  toxemic  type  of  diarrhea  with  general  abdominal  pains 
at  times,  as  the  initial  symptom,  before  localization  of  the  appendix  pain. 
This  is  evidently  of  septicemic  character  and  has  not,  to  my  knowledge, 
heretofore  been  referred  to  as  a  symptom. 

Rudolph  Schmidt^  assumes  that  the  changes  from  normal  in  the  intes- 
tinal flora  of  the  feces,  which  occurs  in  appendicitis,  may  explain  diarrhea 
in  the  early  development  of  this  disease;  or  possibly  acute  enteritis  from 
dietary  indiscretion  may  be  the  cause.  The  type  of  diarrhea  with  gan- 
grenous appendix  seems  to  the  author  pecidiarly  septic  and  is  relieved  by 
appendectomy. 

^  Jour.  Amer.  Med.  Assoc,  Dec.  2,  igio. 
*  Rudolph  Schmidt,  Pain. 


APPENDICITIS  8ll 

6.  In  some  cases  the  thighs  and  knees  are  flexed.^ 

7.  IrritabiHty  of  the  bladder,  if  the  appendix  extends  down  into  the 
pelvis,  may  occur  in  some  cases. 

Appendicitis  in  Infants  and  Children. — Appendicitis  is  more  common 
in  the  male  sex  and  usually  runs  a  rapid  and  severe  course.  In  a  more 
recent  article  Deaver^  states  that  "all  cases  of  abdominal  trouble  in  chil- 
dren are  appendicitis  until  proved  otherwise."  There  should  be  a  sys- 
tematic examination  of  all  organs.  Appendicitis  in  infants  is  difficult  to 
diagnose,  as  the  symptoms  are  often  misleading.  The  younger  the  child, 
the  more  deeply  the  appendix  lies  in  the  pelvis.  Urinary  symptoms  may 
predominate  in  these  cases,  for  example,  cloudy  urine  from  edema  of  the 
bladder,  tenesmus,  and  even  retention.  Pelvic  abscess  is  common  and 
hip-joint  disease  may  be  simulated.  Rectal  examination  is  of  great  im- 
portance as  an  aid  to  diagnosis,  as  an  appendical  abscess  or  enlarged  appen- 
dix can  frequently  be  determined  by  this  method. 

Pain  of  Appendicitis. — The  pain  may  be  sudden  and  violent,  or  at 
times  intermittent  and  cramp-like,  or  even  of  a  gnawing  character  or  a 
dull  ache.  Sudden  and  violent  pain  in  the  initial  stage  does  not  by  any 
means  mean  perforation,  unless  other  symptoms  are  associated.  In 
about  one-half  the  cases  the  pain  begins  in  the  right  iliac  fossa;  it  may  com- 
mence in  the  epigastrium,  around  the  umbilicus,  or  even  be  diffuse,  but 
gradually  becomes  localized  within  twelve  to  twenty-four  or  thirty-six 
hours,  and  usually  sooner. 

At  times  the  pain  is  of  a  colicky  type  (the  so-called  appendicular  colic, 
supposed  by  some  to  be  due  to  constriction  of  the  appendix  in  forcing  out 
mucus  through  a  lumen  nearly  occluded).  Pain  is  increased  on  moving. 
It  is  often  relieved  by  flexing  the  knees  and  thighs,  especially  the  right 
thigh,  and  so  relaxing  the  abdomen.  This  position  is  at  times  assumed  by 
the  patient. 

Palpation  of  the  A  ppendix. — Though  some  surgeons  believe  this  to  be 
an  important  procedure  to  "render  the  diagnosis  certain,  Treves  and  Lock- 
wood  are  very  skeptical  regarding  the  possibility  of  mapping  out  this  organ. 
In  the  chronic  cases  palpation  is  of  value,  and  the  position  and  condition 
of  the  appendix  can  often  be  determined  thereby. 

In  acute  appendicitis  the  methods  oi  forcible  palpation  recommended 
often  necessitate  the  use  of  considerable  pressure,  and  I  believe  the  pro- 
cedure highly  dangerous.  In  the  initial  stages  of  acute  appendicitis,  it  is 
often  impossible  to  at  first  determine  the  character  of  the  attack,  and  trau- 
matism in  some  cases  can  precipitate  a  rupture. 

In  the  acute  cases  gentle  palpation  only  should  be  used.  Percussion, 
according  to  Rudolph  Schmidt,  will  often  demarcate  the  area  of  pain  bet- 
ter than  will  palpation. 

Muscular  Rigidity. — There  is  usually  rigidity  of  the  lower  right  rectus 
muscle  of  varying  intensity. 

Tenderness  on  Pressure. — This  occurs  at  McBurney's  point  and  is  of 
varying  intensity,  also  at  Morris'  point,  and  Blumberg  describes  a  new 
symptom.     There  are  two  points  of  great  diagnostic  value  in  appendicitis: 

^  The  right  thigh  and  knee  are  most  frequently  flexed. 
*  Jour.  Amer.  Med.  Asspc,  Dec.  24,  1910. 


8l2  DISEASES    OF    THE    STOMACH 'AND    INTESTINES 

tenderness  at  McBurney's  point  and  at  Morris'  point  (over  the  right 
lumbar  ganglia). 

McBurney's  Point. — If  a  line  be  drawn  from  the  anterosuperior  spine 
of  the  right  ileum  to  the  umbilicus,  a  point  ij-i  inches  from  the  spine  along 
this  is  known  as  McBurney's  point;  and  deep-seated  tenderness  on  pres- 
sure over  this  point  is  diagnostic  of  appendical  inflammation  when  taken 
in  consideration  with  other  symptoms  (Fig.  323).  Deep  pressure  also 
often  causes  reflex  epigastric  pain.  Berthonier  has  recently  pointed  out 
that  the  examination  in  the  left  lateral  position  produces  severe  pain  over 
McBurney's  point  in  appendicitis,  even  in  cases  where  this  is  not  found 
with  the  patient  in  the  dorsal  position. 

Mere  superficial  tenderness  means  irritation  of  the  sensory  nerves  of 
the  abdominal  wall  due  to  hysteria,  etc. 


Fig.  323. — A,  McBurney's  point;  B,  R.  T.  Morris'  point  (lumbar  ganglia)  in 

appendicitis. 

Munro's  point  is  slightly  further  out,  where  the  same  line  crosses  the 
outer  border  of  the  rectus. 

Lanz's  Point. — This  observer  draws  a  line  between  the  two  antero- 
superior iliac  spines,  and  divides  this  line  into  three  equal  parts.  He 
claims  that  the  first  point  of  division  corresponds  to  the  base  of  the  ap- 
pendix and  that  McBurney's  point  is  too  high  up. 

Morris^  Point.^ — "Take  another  point  on  the  line  between  the  umbili- 
cus and  anterosuperior  spine  of  the  ileum,  but  13.2  inches  from  the  navel, 
which  lies  over  the  right  lumbar  ganglia  of  the  sympathetic  system,  and 
we  have  another  point  of  diagnostic  value  when  tenderness  on  pressure  is 
located  in  this  region. 

"i.  In  the  early  stages  of  an  acute  infective  process  of  the  appendix, 
the  right  lumbar  ganglia  are  not  tender.  (The  left  lumbar  ganglia  may 
be  described  for  diagnostic  purposes  as  lying  i>^  inches  to  the  left  of  the 

*  Surgical  Section,  New  York  Academy  of  Medicine,  Dec;.  5,  1907.  The  author  here 
quotes  Morris'  deductions. 


APPENDICITIS  813 

navel.)  Under  these  circumstances  the  point  here  described  is  of  second- 
ary importance,  while  McBurney's  point  is  of  prime  consequence. 

"2.  A.  When  an  acute  inflammatory  process  of  the  appendix  has  sub- 
sided, leaving  a  mucous  inclusion  or  scar  tissue,  there  may  be  no  tender- 
ness on  pressure  at  McBurney's  point,  but  there  is  tenderness  at  the  point 
here  described  and  no  tenderness  at  the  point  of  the  left  lumbar  ganglia. 

"5.  When  the  appendix  is  undergoing  an  involution  process,  with 
replacement  of  its  lymphoid  coats  by  connective  tisstie,  digestive  disturb- 
ances and  various  local  neuralgias  may  be  due  to  irritation  of  n^rve-fila- 
ments  entrapped  in  the  new  connective  tissue.  There  may  be  no  tender- 
ness at  McBurney's  point,  but  there  is  persistent  tenderness  at  the  point 
here  described.  There  is  no  tenderness  at  the  point  of  the  left  lumbar 
ganglia." 

The  above  condition  constitutes  fibroid  degeneration  of  the  appendix. 

"C.  When  the  appendix  is  congested  without  the  presence  of  infec- 
tion, as  in  many  cases  of  loose  kidney,  there  may  be  little  or  no  tenderness 
at  the  point  here  described.  There  is  no  tenderness  at  the  point  of  the 
left  lumbar  gangha." 

The  author  wishes  to  state,  as  before,  that  this  type  of  appendical 
congestion  he  believes  is  not  due  to  loose  kidney  pressure,  but  is  dependent 
on  the  enteroptosis. 

"In  irritations  of  pelvic  origin,  both  right  and  left  lumbar  ganglia  are 
tender.  Take,  for  illustration,  a  case  in  which  the  appendix  and  the 
right  Fallopian  tube  are  bound  together  by  adhesions.  We  are  to  decide 
whether  certain  symptoms  proceed  from  the  appendix  or  from  the  Fal- 
lopian tube.  If  the  symptoms  proceed  from  the  appendix,  the  point  here 
described  is  tender  alone.  If  the  symptoms  proceed  from  the  Fallopian 
tube,  both  right  and  left  lumbar  ganglia  are  tender  together. 

"To  recapitulate:  A  patient  comes  in  with  the  appendix  in  the  form  of 
a  question  mark.  Right  lumbar  ganglia  tender  alone — appendix  trouble. 
Right  and  left  lumbar  ganglia  tender  together — pelvic  trouble.  Neither 
right  nor  left  lumbar  ganglia  tender — trouble  somewhere  cephalad  from 
pelvis  and  appendix." 

Superficial  Reflexes  of  the  Abdominal  Wall. — In  appendicitis  the  skin 
reflexes  of  this  region  are  frequently  absent  or  markedly  diminished. 
The  return  of  the  lost  reflexes  is  usually  synchronous  with  other  evidences 
of  recovery. 

Blumberg^  describes  a  sign  pointing  to  peritoneal  irritation  or  inflam- 
mation, which  he  considers  will  be  found  of  assistance  in  the  diagnosis  of 
all  peritoneal  conditions,  and  especially  of  appendicitis.  It  consists  in 
the  fact  that  on  palpating  the  abdomen  in  the  neighborhood  of  an  area  of 
inflamed  peritoneum,  not  only  is  the  downward  pressure  painful,  but,  if 
the  examining  hand  is  suddenly  removed,  the  abrupt  recoil  of  the  abdominal 
wall  also  gives  rise  to  pain.  He  has  found  that  during  an  acute  attack  of* 
appendicitis  with  peritoneal  involvement,  patients  invariably  state  that 
the  pain  caused  by  the  sudden  removal  of  the  hand  is  greater  than  that 
caused  by  the  pressure,  while  if  the  inflammatory  process  is  subsiding,  the 
two  painful  sensations  first  become  equal  in  intensity,  and  finally  the  pres- 
'  Miinchener  med.  Wochenschr.,  June  11,  1907. 


8l4  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

sure  pain  is  greater  than  the  other.  He  further  believes  that  the  sign  is 
especially  valuable  in  determining  whether  or  not  operation  is  indicated 
in  early  cases,  since  its  presence  indicates  that  the  peritoneum  has  already 
begun  to  take  part  in  the  inflammation.  Its  sudden  appearance  is,  there- 
fore, a  danger  signal,  while  its  gradual  diminution  in  intensity  points  to  a 
subsidence  of  the  peritoneal  reaction.  The  advantage  of  the  method  is 
that  it  does  not  require  an  absolute  estimation  of  the  degree  of  pain  caused 
by  the  palpation,  which  is  often  difficult  to  obtain,  but  demands  simply 
a  comparison  of  the  intensity  of  the  two  painful  stimuli,  which  most 
patients  are  able  to  determine  accurately. 

S.  J.  Meltzer^s  Method. — Meltzer  extends  the  right  knee,  at  the  same 
time  flexing  the  right  thigh,  while  making  pressure  over  McBurney's 
point.  This  projects  the  psoas  muscle  against  the  appendix  and  causes 
deep-seated  tenderness  in  the  appendix  to  be  more  readily  appreciated. 

H.  lUoway^  holds  that  forced  flexion  and  especially  forced  extension 
of  the  right  thigh  will  cause  pain  in  the  appendix  if  inflammation  is  present. 

Rovsing-Chase  Method. — The  patient  is  preferably  placed  on  a  hard 
low  bed  or  table.  The  knees  should  be  flexed  and  two  pillows  placed 
under  the  head  and  shoulders,  giving  a  dorsal  semirecumbent  position, 
and  thus  rendering  the  abdomen  flaccid  for  a  satisfactory  abdominal 
compression.  The  examiner  stands  on  the  patient's  left,  facing  the  feet. 
The  palmar  surfaces  of  the  fingers  of  the  right  hand  are  placed  at  the  low- 
est part  of  the  patient's  left  inguinal  region,  and  the  fingers  of  the  left 
hand  are  used  to  reinforce  the  right.  Deep  pressure  is  then  made  back- 
ward along  the  descending  colon,  the  fingers  being  slowly  drawn  upward, 
toward  and  under  the  left  costal  arch.  By  this  procedure,  the  lower  por- 
tion of  the  descending  colon  is  compressed  and  its  gaseous  content  forced 
into  the  transverse,  and  thence  into  the  ascending  colon.  The  pressure 
over  the  descending  colon  being  maintained  with  the  fingers  of  the  left 
hand,  the  right  hand  is  then  removed  and  placed  over  the  upper  part  of 
the  descending  colon,  or,  preferably,  over  the  transverse  colon,  and  the 
fingers  are  quickly  and  forcibly  depressed.  A  gaseous  compression  wave 
will  travel  across  the  transverse  and  down  the  ascending  colon,  and  on 
arriving  at  the  cecum  will  produce  distention,  producing  a  typical  sharp 
pain  in  the  right  iliac  fossa,  if  inflammation  of  the  cecum  or  appendix  be 
present.  This  method  is  of  chief  value  in  testing  for  chronic  appendicitis. 
Bastedo's  Method  for  Testing  for  Chronic  Appendicitis. — A  colon  tube  is 
passed  ii  or  12  inches  into  the  rectum  and  air  is  injected  by  means  of  a 
bulb;  that  of  an  atomizer  may  be  employed.  If  as  the  colon  distends, 
pain  and  tenderness  on  pressure  by  the  finger  point  occur  at  McBurney's 
point,  then  chronic  appendicitis  is  present.  Most  of  the  air  should  be 
allowed  to  escape  before  removal  of  the  tube  to  avoid  subsequent  colicky 
pains.  This  method  aids  differentiation  between  appendicitis  and  right 
tubo-ovarian  inflammation. 

In  many  cases,  especially  in  the  acute  catarrhal  conditions  or  in 
the  most  virulent  gangrenous  type,  no  induration  or  swelling  can  be 
appreciated   on  palpation.     Under   such   conditions   forcible  palpation 
in  the  endeavor  to  appreciate  the  appendix  should  be  avoided. 
^  Arcliiv  of  Diagnosis,  July,  1908. 


APPENDICITIS  815 

Percussion. — In  cases  with  adhesions,  exudation  without  pus,  or 
of  abscess,  a  boggy  or,  rarely,  fluctuating  mass  can  be  appreciated  in 
the  right  ihac  fossa,  and  percussion  will  give  a  dull  area  in  the  region 
of  the  cecum.  Fecal  accumulation  as  a  result  of  constipation  must 
be  differentiated  by  the  methods  I  have  already  indicated. 

At  times  great  irritability  of  the  bladder  is  associated  with  this  con- 
dition and  the  urine  may  be  scanty  and  contain  indican  and  albumin 
and  casts,  and  even  acute  nephritis  may  be  present. 

Rectal  and  vaginal  examination  often  aid  in  localizing  the  condi- 
tion if  the  appendix  or  abscess  lie  in  the  pelvis.  In  single  women  one 
should  employ  rectal  examination.  These  methods  also  aid  differential 
diagnosis.  Inspection  may  occasionally  show  protrusion  on  the  right 
side  or  the  distention  of  general  peritonitis. 

If  ticmcr  is  present,  it  may  be  variable  in  size,  and  it  lies  more  fre- 
quently in  the  right  iliac  fossa.  Its  position,  however,  depends  on  that 
of  the  appendix,  as  already  described. 

Temperature. — An  initial  chill  is  rare.  In  the  acute  cases  fever, 
even  though  slight,  is  present  in  the  early  stages.  It  may  be  only  99.5°F. 
or  keep  low,  or  even  rise  to  101°  or  io2°F.,  or  to  a  considerable  height. 

Sometimes  with  circumscribed  abscess  there  may  be  for  a  time 
only  moderate  temperature,  and  some  cases  of  the  virulent  type  will 
suddenly  perforate,  though  the  temperature  be  not  high.  In  both 
of  these  the  physical  examination,  the  blood-count,  and  general  symptoms 
will  aid  the  diagnosis. 

In  general,  a  rise  of  temperature  is  significant  of  an  active  process, 
even  though  the  temperature  increase  may  be  slight  in  degree  and  gradual 
in  character.  A  slight  increase  in  rapidity  of  the  pulse  is  also  suggestive 
of  an  acute  process,  and  at  times  this  is  noticeable  much  out  of  proportion 
to  tJie  temperature,  especially  the  rapid  pulse  in  gangrene  or  sudden  perforation. 

Gastro-intestinal  Symptoms. — ^Loss  of  the  appetite  and  coated 
tongue  are  present.     Emaciation  may  occur  in  cases  of  long  duration. 

In  the  severer  cases  vomiting  is  quite  common.  It  may  be  one  of 
the  first  symptoms  occurring  with  the  pain,  and  then  cease,  or  it  may 
continue  for  several  days.  On  the  other  hand,  it  may  come  on  later  in 
the  attack  and  denote  an  exacerbation  of  the  inflammation.  It  consists 
of  the  stomach  contents,  mucus,  and  bile;  and  in  some  cases  it  may  be 
feculent.     Associated  with  it  there  is  at  times  hiccup. 

Black  vomit  ("vomito  negro  appendiculaire  ")  is  the  result  of  toxemia, 
producing  hemorrhagic  necrosis  of  the  mucosa  of  the  stomach  and 
hematemesis. 

A  few  cases  have  also  been  reported  of  intestinal  hemorrhage  asso- 
ciated with  jaundice  and  albuminuria.  These  conditions  are  all  evi- 
dences of  a  fatal  sepsis.  Acute  ectasia  or  acute  gastro-intestinal  dilatation 
may  also  occur  as  complications. 

Bowels. — In  some  cases  the  bowels  are  regular,  until  the  attack, 
when  constipation  ensues.  In  others  there  may  be  a  previous  history 
of  constipation.  Diarrhea  of  a  toxemic  type  may  be  one  of  the  initial 
symptoms  in  acute  gangrenous  appendicitis.     It  is  probably  of  septicemic 


8i6 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


character.     I  have  noted   it  in  several  such  cases.     Intestinal  paresis 
may  occur  as  a  complication. 

Tumefaction  or  Abscess. — In  cases  of  acute  appendicitis  in  which 
adhesions  are  present,  a  tumor  due  to  adhesions  and  exudation,  or  an 
actual  abscess,  the  position  of  the  mass  is  dependent  upon  the  position 
of  the  appendix  primarily  and  then  upon  the  direction  of  the  extension  of 
the  inflammation  or  burrowing  of  the  pus.  It  may  pass  down  into  the 
pelvis  and  produce  bladder  and  rectal  symptoms,  or  those  pointing  to 
the  tubes  and  ovary  (right),  and  be  palpable  through  the  rectum  and 
vagina.  It  may  point  below  Poupart's  ligament  or  simulate  a  psoas 
abscess.     It  may  pass  around  in  front  of  the  cecum  and  superficial  edema 

be  noted  in  this  region,  or  posteriorly  to 
the  cecum  and  cause  pain  in  the  flank  or 
back,  with  swelling,  and  produce  perine- 
phritic  abscess  or  lumbar  abscess.  It  may 
pass  inward  to  the  left,  even  to  the 
spleen,  or  produce  obstruction  through 
pressure  or  bands,  or  upward  and  produce 
subphrenic  abscess  (Fig.  324),  and  even 
perforate  the  diaphragm,  pleura,  and 
lungs.  It  may  develop  in  a  hernial  sac. 
RetroperitoneaF  rupture  of  the  appendix 
has  occurred  with  subsequent  extravasa- 
tion of  pus  into  the  thigh  resulting  in 
gangrene. 

At  times  the  tumor  appears  at  the 
lower  border  of  the  liver,  when  the  tip 
of  the  appendix  lies  in  this  region.  The 
condition  must  then  be  differentiated  be- 
tween retroverted  appendical  abscess  and 
gall-bladder  or  renal  inflammation,  such  as 
infarction. 

Brewer  has  shown  that  tenderness  at 
the  costovertebral  angle  is  diagnostic  of  the 
latter;  the  urine  analysis  is  also  important, 
and  especially  differential  analysis  after 
catheterization  of  both  ureters.  Determi- 
nation of  Head's  zones  may  also  aid  in  the 
diagnosis.  The  history  will  usually  point  to  appendicular  inflammation 
or  disease  of  the  gall-bladder,  but  operative  procedure  will  alone  settle 
some  cases. 

The  value  of  Head's  zones  of  cutaneous  hyperalgesia  as  an  aid  to 
differential  diagnosis  will  be  referred  to  under  that  section. 

The  elements  in  the  diagnosis  of  abscess  formation  are  the  grad- 
ual increase  of  the  local  tumor  and  the  aggravation  of  the  general  symp- 
toms. The  abscess  may  perforate  and  cause  a  general  peritonitis  or  the 
inflammation  may  extend  to  the  peritoneum  without  perforation,   so 


Fig.  324. — D,  Diaphragm; 
L,  liver;  K,  kidney;  P,  perito- 
neum; C,  colon.  The  appendix 
lies  behind  the  cecum  and  colon. 
The  dotted  area  indicates  the 
retroperitoneal  spread  of  appen- 
dical inflammation  to  the  cellular 
tissues  around  the  kidney  and  the 
under  surface  of  the  liver 
(Cantlie). 


^  Journal  A.   M.  A.,  June   7,   1913. 


APPENDICITIS  817 

that  there  may  be  a  slower  process  with  various  sacculated  collections  of 
pus. 

The  abscess  may  rupture  through  the  skin  or  empty  into  the  cecum, 
colon,  small  intestine,  bladder,  rectum,  or  pelvis  of  the  kidney. 

Fulminating  Type  of  Acute  Appendicitis. — This  is  the  most  dangerous 
and  fatal  of  all.  This  type  of  appendicits  can  be  subdivided  into  two 
clinical  varieties.  Both  are  characterized  by  the  rapidity  of  the  patho- 
logic changes  in  the  appendix  and  by  the  absence  of  protective  peritoneal 
adhesions,  so  that  general  peritoneal  infection  occurs  quite  rapidly. 

In  the  first  class  the  pain  in  the  region  of  the  appendix  and  some 
of  the  subjective  and  objective  symptoms  are  acute  and  quite  marked 
but  not  all  of  them. 

In  the  second  class,  and  by  far  the  most  dangerous  because  fre- 
quently undiagnosed  until  the  general  infection  has  occurred,  the  patient 
complains  of  no  marked  subjective  symptoms;  in  fact,  may  say  he  is 
quite  comfortable,  and  the  objective  symptoms  are  not  marked.  There 
are  peculiarities  in  the  pulse,  temperature,  and  especially  in  the  blood 
changes  which  tell  the  story. 

Acute  gangrene  of  the  appendix,  with  or  without  perforation,  is 
the  pathologic  condition  generally  found  in  operation;  though  I  have 
also  seen  an  acute  diffuse  or  purulent  inflammation  of  the  appendix, 
either  with  perforation  or  without  it,*  produce  the  condition.  In  some 
cases  perforation  was  apparently  due  to  ulceration  from  a  fecal  concretion 
which  was  found  in  the  cavity.  Perforation  undoubtedly  is  present  in 
many  cases,  but  I  agree  with  Riegel  that  acute  virulent  infection  of  the 
peritoneum,  commencing  in  the  region  of  the  appendix,  will  produce  the 
same  clinical  symptoms. 

In  the  first  class  of  cases  the  patient  may  have  given  a  history  of 
previous  attacks  or  have  had  some  indefinite  abdominal  symptoms 
for  several  days,  or  may  be  attacked  without  warning,  as  in  the  mid- 
dle of  the  night,  with  severe  pain  in  the  abdomen.  It  may  not  at  first 
be  referred  to  the  appendical  region,  may  be  epigastric  or  umbilical  pain, 
but  gradually  localizes  there.  There  is  no  tumor,  the  muscles  are  rigid, 
the  appendix  tender.  The  abdomen  rapidly  distends.  The  patient  is 
anxious  and  looks  sick.  The  temperature  at  first  may  not  be  elevated 
much.  The  pulse  is  rapid  and  out  of  proportion  to  the  temperature. 
General  symptoms  of  peritonitis  rapidly  ensue.  In  others  the  pulse  may 
be  slow  at  first  and  a  low  temperature  with  local  signs  of  appendicitis,  but 
acute  history,  nausea,  vomiting,  and  marked  constipation.  The  pulse 
later  becomes  more  rapid,  high  temperature,  distention,  coated  tongue, 
and  general  tenderness. 

In  others  the  first  symptoms  are  of  collapse,  with  subnormal  tem- 
perature, rapid  pulse,  cold  and  clammy  skin,  respiration  increased  in 
frequency,  followed  by  symptoms  of  general  peritonitis. 

In  the  second  class  of  cases  the  condition  may  be  very  deceptive. 
The  patient,  in  perfect  health,  may  suddenly  complain  of  general  abdom- 
inal pains.  I  have  seen  a  number  with  diarrhea  of  toxic  character  as  the 
initial  symptom.  The  patient  may  impute  the  symptoms  to  dietary 
indiscretions.  The  tenderness  may  be  diffuse  or  equal  on  both  sides,  and 
52 


8l8  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

gradually  it  localizes  in  the  appendix  region.  Even  so,  the  tenderness  at 
McBurnery's  point  may  not  be  very  acute,  and  the  rigidity  of  the  right 
rectus  not  very  marked  or  very  slight.  The  patient  may  state  that  he 
feels  quite  comfortable.  The  temperature  may  be  moderate  (ioo°F.) 
and  the  pulse  loo. 

The  temperature  tends  to  gradually  creep  up,  the  pulse  to  increase  in 
rapidity  out  of  proportion  to  the  temperature  increase,  which  last  may  be 
slight,  and  the  character  of  the  pulse  changes;  the  patient  looks  more  sick, 
but  still  complains  of  no  special  symptoms  except  slight  pain  or  exacer- 
bations of  it  in  the  right  side,  and  still  feels  comfortable. 

The  blood  examination  shows  in  many  cases  moderate  leukocytosis 
(14,000  to  16,000),  but  marked  increase  in  the  polynuclears  (88  to  92  per 
cent.).  Hyperinosis  is  present.  The  patient  presents  as  yet  no  symptoms 
of  general  peritonitis,  but  nevertheless  the  sepsis  is  marked  in  these 
cases,  and  unless  immediate  operation  is  performed  will  have  a  virulent 
type  of  septic  peritonitis. 

A  patient  of  mine  operated  on  by  the  late  Frank  Hartley  presented  the 
mild  type  of  symptoms  just  described;  diarrhea  at  4  p.m.;  no  appendical 
pain  or  tenderness;  localized  appendical  pain  at  midnight,  when  the  sur- 
geon was  at  once  called  in.  Differential  blood-count  at  8  A.  m.  and  i  p.  m., 
showing  a  gradual  increase  in  polynuclears  and  low  leukocytosis  (15,000 
to  16,000).  The  patient  was  quite  comfortable;  no  distention;  slight  pain 
over  appendix,  but  the  temperature  and  pulse  slowly  creeping  up. 

At  5  A.  M.  operation  at  the  New  York  Hospital;  acute  gangrene  of 
appendix  and  commencing  peritonitis;  ultimate  recovery. 

The  examination  of  the  blood  is  thus  imperative  when  possible.  Brewer,* 
however,  reports  one  case  of  acute  gangrenous  appendicitis  in  which 
the  blood  count  was  within  the  normal  limit,  a  temperature  of  only  99.2°F., 
and  the  only  evidence  of  severe  disease  was  a  well-marked  rigidity  of  the 
lower  half  of  the  right  rectus  muscle.  One  must  also  remember  that  in 
the  course  of  tabes,  acute  appendicitis  has  occurred  even  with  perforation, 
and  with  the  formation  and  rupture  of  an  abscess  or  with  diffuse  peri- 
tonitis, with  little  or  no  pain,  and  with  very  few  local  evidences  of  an 
inflammatory  process.  Connors^  reports  an  interesting  case.  The 
patient  had  chills,  irregular  temperature,  later  vomiting  and  leukocytosis. 
There  were  no  pain,  tenderness,  and  muscular  rigidity.  Autopsy  showed 
perforative  appendicitis  and  diffuse  peritonitis.  There  were  found  the 
spinal  lesions  of  tabes  dorsalis. 

The  Blood  in  Acute  Appendicitis. — Hyperinosis  (increased  fibrin 
in  the  blood)  has  been  demonstrated  by  E.  E.  Smith  and  Bartlett^  to 
be  more  marked  in  direct  proportion  to  the  involvement  of  the  serous 
surface,  and  hence,  depending  on  its  degree,  is  suggestive  of  proportional 
peritonitic  infection. 

One  of  the  most  important  factors  in  the  determination  as  to  operative 
procedure  in  appendicitis  and  as  to  the  relative  severity  of  the  case  is  the 
differential  leukocyte  count.    Charles  Langdon  Gibson  has  especially  pointed 

^  Masked  Appendicitis,  N.  Y.  State  Jour,  of  Med.,  March,  1910. 

^  Jour.  Amer.  Med.  Assoc,  Oct.  22,  1910. 

*  Blood  Reactions  of  Inflammation,  Med.  Rec,  Feb.  8,  1908. 


APPENDICITIS 


819 


out  that  it  is  the  disproportion  between  the  percentage  of  polynuclear 
cells  and  the  total  leukocytosis  that  is  important. 

The  chart  (Fig.  325)  assumes  that  10,000  leukocytes  per  cubic  milli- 
meter is  the  upper  limit  of  ordinary  normal  leukocytosis,  and  that  75  is 
the  normal  percentage  of  polynuclears.  Gibson  further  assumed  that 
in  inflammations  which  are  well  resisted  the  polynuclear  cells  are  increased 
approximately  by  i  per  cent,  for  every  1000  leukocytes  above  the  normal 
10,000  per  cubic  millimeter.  Thus  in  the  chart  the  horizontal  line  will 
indicate  a  leukocyte  count  of  11,000  with  76  per  cent,  of  polynuclears, 
whereas  the  rising  line  represents  a  leukocytosis  of  11,000,  but  with  86 
per  cent,  of  polynuclears. 

If  the  line  connecting  the  total  leukocytes  and  the  percentage  of 
polynuclears  runs  fairly  horizontal,  it  indicates  a  lesion  that,  whether 
severe  or  not,  is  well  borne  and,  therefore,  of 
good  prognosis. 

If  the  line  runs  upward  from  the  leuko- 
cyte to  the  polynuclear  side,  it  indicates  a 
rather  severe  lesion  and  less  resistance. 

Fatal  cases  all  have  a  rising  line. 

A  falling  line  (e.g.,  leukocytosis  of  30,000 
with  80  per  cent,  of  polynuclears)  means  a 
mild  lesion;  in  appendicitis  it  would  probably 
indicate  an  abscess  well  shut  off,  with  little 
febrile  or  constitutional  disturbance. 

Gibson's  conclusions  are  as  follows:  The 
differential  blood-count  and  its  relation  to 
the  total  leukocytosis  is  the  most  valuable 
diagnostic  and  prognostic  aid  in  acute  sur- 
gical diseases  that  is  furnished  by  any  of 
the  methods  of  blood  examination. 

It  is  of  chief  value  in  indicating  fairly 
consistently  the  existence  of  suppuration  or 
gangrene,  as  evidenced  by  an  increase  of  the 
polynuclear  cells  disproportionately  high  as 
compared  to  the  total  leukocytosis. 

The  Gibson  chart  is  to  a  certain  extent 
schematic,  as  it  is  only  applicable  to  a  leucocyte  count  of  about  25,000, 
since  if  it  were  30,000  or  over,  there  could  only  be  a  rise  of  5  units  in  the 
polynuclears,  and  this  would  be  100  per  cent.,  which  never  occurs.  It 
would  also  suggest  a  good  prognosis  according  to  his  unit  system  of  rise 
and  fall.  One  can  apply  Gibson's  principles  for  the  higher  counts  by 
the  chart  (Fig.  326),  as  suggested  by  Coons  and  Bratton.*  Sondern 
substantially  employs  this  same  type  of  chart. 

E.  E.  Smith^  shows  that  the  differential  blood-count  is  an  indicator 
of  the  activity  of  the  process  and  not  invariably  of  gangrene;  but  if  the 
absolute  leukocytosis  is  low  (below  15,000),  with  high  polynuclears,  it  is 
probably  gangrene. 

*  Prognostic  and  Diagnostic  Value  of  the  Leukocytes  and  Differential  Count  in 
Acute  Abdominal  Infection,  N.  Y.  Med.  Jour.,  July  21,  1909. 
'  Blood  Reactions  of  Inflammation,  Med.  Rec,  Feb.  8,  1908. 


Fig.  325. — C.  L.  Gibson's 
differential  chart  for  leukocy- 
tosis. 


820 


DISEASES    OF   THE    STOMACH   AlSTD   INTESTINES 


Gibson  further  holds  that  the  greater  the  disproportion  the  surer 
are  the  findings,  and  in  extreme  disproportions  the  method  has  proved 
itself  practically  infallible. 

As  the  relative  disproportion  between  the  leukocytosis  and  the  per- 
centage of  the  poynuclear  cells  is  of  so  much  more  value  than  the  findings 


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^oOO 

Leucocytes, 


of   the   gallbtadJer.    Leucocytes.    4,300;    polynuclear, 
poly  nuclear, 
polynuclear.    9J    per 
Leucocyte: 


Perforation,    typhoid    fever. 
95  per  cent     Fatal. 

c-     Puerpural    sepsis.      Leucocytes,    14,000 
cent.     Fata). 

rf.     Gangrenous     perforative     appendicitis, 
polynuclear,  90.2   per  cent.     Recovery. 

t.    Appendicitis,    local    peritonitis.      Leucocytes,    40,000;    polyna> 
dear,  89.9  per  cent.     Recovery. 

/.    Appepdicttis,  spreading  peritonitis.     Lei^cocytes,  49,009;   poly* 
6ncletr>  ^6  per  ccat.     Recorery, 


23,000; 


Fig.  326. — Blood-count  chart  (Sondern). 

based  on  a  leukocyte  count  alone,  this  latter  method  should  be  abandoned 
.in  favor  of  the  newer  and  more  reliable  procedure. 

The  negative  findings,  showing  no  relative  increase  or  even  an  actual 
decrease  of  the  proportion  of  the  polynuclear  cells,  while  of  less  value, 
show  with  rare  exceptions  the  absence  of  the  severer  forms  of  inflammation. 

In  its  practical  applications  the  method  is  of  fnore  frequent  value 


APPENDICITIS  821 

in  the  interpretation  of  the  severity  of  the  lesions  of  appendicitis  and 
their  sequelae. 

Though  N.  E.  Ditman,  in  a  paper  read  before  the  Obstetrical  Section 
of  the  Academy,  November,  1906,  criticizes  the  differential  count  as  of 
doubtful  value,  Sondern^  shows  that  in  cases  quoted  the  pus  was  encap- 
sulated in  such  a  way  that  no  toxic  absorption  occurred,  and  also  demon- 
strates that  polynuclear  increase  may  occur  in  other  than  suppurative 
conditions. 

It  is  a  well-known  fact  that  such  encapsulated  abscesses  may  occur 
without  marked  constitutional  symptoms,  hut  physical  signs  determine 
their  presence. 

In  this  type  the  processes  are  less  active,  and  this  is  probably  the 
chief  cause. 

I  have  seen  a  very  low  leukocytosis  with  a  general  fatal  peritonitis, 
the  system  evidently  being  overwhelmed  by  the  poison.  The  physical 
signs,  with  increased  polynuclears  and  hyperinosis,  aid  our  diagnosis 
in  all  but  exceptional  cases. 

A  low  leukocytosis  with  high  polynuclear  count  also  shows  poor  resist- 
ing power  to  the  infecion. 

To  recapitulate:  We  may.  have  numerous  types  of  acute  appendi- 
citis, which  clinically  are  as  follows: 

1.  Simple  catarrhal  appendicits  with  mild  symptoms,  lasting  a  few 
days  to  a  week  or  ten  days;  often  secondary  to  colitis,  intestinal  dis- 
turbances, or  fecal  impaction  in  the  caput  coli;  blood  changes  are  moderate 
and  the  attack  soon  subsides  under  medica'  treatment  combined  with  the 
ice-bag.     It  may  never  recur. 

2.  Acute  appendicits  (diffuse),  symptoms  more  severe;  may  be 
adhesions  or  slight  exudation;  temperature  higher;  more  marked  tender- 
ness; tumor  often  palpable,  but  may  disappear.  It  may  become 
chronic  or  recurrent,  or  occasionally  perforate. 

3.  Acute  appendicitis,  with  abscess,  chills,  tumor,  etc.,  present. 
Abscess  may  perforate. 

4.  Fulminating  type,  perforation  or  gangrene. 

Remote  Effects  of  Acute  Appendicitis. — They  are  as  follows:  Hemor- 
rhage from  perforation  of  a  blood-vessel;  suppurative  pylephlebitis; 
pyelitis;  thrombosis  of  the  iliac  or  femoral  veins;  pulmonary  embolism; 
pericystitis;  strangulation  of  the  bowel;  subsequent  symptoms  may  occur 
due  to  incomplete  removal  or  subsequent  adhesions.  Hartley  has  noted 
intestinal  paresis  in  mild  cases,  with  symptoms  of  ileus  resulting;  also 
infection  of  the  mesenteric  glands,  subsiding  in  some  cases  after  appendec- 
tomy, and  in  others  causing  subsequent  inflammation.  Acute  dilatation 
of  the  stomach  may  occur.  Cellulitis  of  the  abdominal  wall  has  occurred. 
Subphrenic  abscess  has  followed  acute  appendicitis  especially,  the  retro- 
verted  appendix  extending  to  the  liver  or  from  appendical  abscess.  Box,'^ 
Russel  and  Neuhof^  report  cases  of  non-suppurative  subphrenic  inflam- 
mation complicating  appendical  abscess. 

1  N.  Y.  Med.  Jour.,  June  26,  1907. 

2  St.  Thomas  Hosp.  Reports,  vol.  xxvi,    1891. 
'  Surgery,  Gynec.  and  Obst.,  March,   191 2. 


82  2  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

Postoperative  stomach  and  intestinal  hemorrhage  after  appendi- 
citis operations  are  described  by  Schwalbach,^  who  collected  30  cases. 
They  are  more  frequent  in  children  and  in  men.  There  are  hemorrhages, 
erosions,  and  ulcerations  in  the  stomach  and  intestines  due  to  thrombosis 
in  the  circulatory  system  of  the  omentum  and  mesentery.  The  hemor- 
rhage is  from  erosions.  These  cases  are  septic  and  the  prognosis  is  bad. 
They  are  described  as  the  vomito-negro-appendiculaire. 

Chronic  Appendicitis. — This  may  follow  an  ordinary  acute  attack, 
or  be  chronic  from  its  incipiency. 

The  latter  often  is  secondary  to  chronic  intestinal  catarrh.  The 
patient  has  frequently  a  continuous  feeling  of  discomfort  in  the  appendical 
region;  slight  tenderness  on  pressure;  generally  intestinal  and  frequently 
nervous  disturbances  associated,  also  obstinate  constipation  and  more 
rarely  diarrhea  or  gastric  disturbances  even  with  headache,  nausea,  or 
vomiting.  Some  of  the  symptoms  may  simulate  gastric  or  duodenal 
ulcer,  or  cholelithiasis  or  achlorhydria  haemorrhagica  gastrica  may  be 
secondary,  or  there  may  be  persistent  vomiting.  There  may  be  hyper- 
acidity or  hypo-acidity  of  the  stomach,  or  achlorhydria,  or  the  findings 
may  be  normal.  Renal  disease,  or  renal  calculus,  or  ureteral  calculus  may 
be  simulated.  In  my  own  experience  vomiting  is  not  so  prominent  a 
symptom  in  chronic  appendicits  as  with  gastric  ulcer,  and  when  vomiting 
occurs  it  more  frequently  consists  of  food  rather  than  sour  liquid.  Nausea 
is  more  characteristic.  There  may  be  pain  or,  more  frequently,  distress 
shortly  after  eating,  which  may  continue  for  a  time.  The  pain  may  be 
epigastric,  but  is  more  frequently  indefinitely  or  plainly  abdominal 
in  chronic  appendicitis.  Pylorospasm  may  occur.  Pressure  over  the 
appendix  at  McBurney's  point  or  pressure  at  Morris'  point  may  pro- 
duce reflex  pain  or  discomfort  in  the  epigastrium.  Aaron^  reports  reflex 
pylorospasm  seen  by  fluoroscopy  in  one  case  occurring  as  a  result  of  pres- 
sure on  the  appendix.  Orthoform  or  anesthesin  relieves  the  pain  of  ulcer, 
but  not  that  of  chronic  appendicitis.  Slight  tenderness,  or  discomfort 
on  pressure  at  McBurney's  point  may  be  present.  This  may  disappear 
for  periods.  At  times  no  tenderness  can  be  elicited  on  pressure  at 
McBurney's  point  but  there  is  a  referred  distress  or  pain  in  the  epigas- 
trium, or  in  the  percordial  region.  Discomfort  or  pain  on  pressure  is 
found,  however,  at  Morris'  point.  Examination  of  this  point  is  frequently 
neglected.     There  may  be  exacerbations  of  acute  attacks. 

Appendicitis  Claudicans. — Rochard^  and  Stem  apply  this  term  to 
cases  of  chronic  appendicitis  which  presented  two  misleading  symptoms, 
pain  referred  by  the  patient  to  the  right  hip  and  intermittent  claudication 
coming  on  after  fatigue.  The  pain  was  ascribed  to  neuritis  of  the  crural 
or  abdomino-genital  nerves.  They  suffered  from  nausea,  anorexia, 
flatulence  and  constipation  with  occasional  diarrheal  attacks,  and  tender- 
ness at  McBurney's  point,  complaining  chiefly  of  claudication  and  pain 
in  the  right  limb.     All  recovered  after  appendectomy. 

Indiscretions  in   diet   often  cause   exacerbations  of  the  symptoms. 

^  Deutsch.  Zeit.  fiir  Chir.,  Bd.  95,  H.  1-5,  p.  141. 
^Journal  A.  M.  A.,  May  29,  1915. 
'  Presse  Medicale,  Oct.  11,  1913. 


APPENDICITIS  823 

In  some  of  these  cases  there  is  simply  a  chronic  catarrhal  condition, 
but  more  frequently  angulation  with  adhesions. 

Serious  conditions  are  at  times  found  in  the  appendix  in  these  chronic 
cases,  and  a  brief  reference  to  such  is  important.  A  patient,  F.  J.  G., 
age  thirty-five,  financier,  with  a  history  of  a  mild  appendical  attack 
three  years  ago,  presented  the  following  symptoms:  For  a  period  of  three 
weeks  a  feeling  of  general  malaise,  appetite  capricious,  pains  in  the  neck 
and  limbs,  occasional  belching,  considerable  intestinal  gas;  occasional 
discomfort  and  tenderness  on  pressure  in  the  right  iliac  region.  Patient 
at  times  awakened  by  gas-pressure;  occasional  chilly  feelings.  He  came 
to  the  office  for  examination;  temperature  99°F.;  slight  tenderness  on 
pressure  over  the  appendix;  somewhat  higher  and  nearer  median  line 
than  usual;  leukocytosis  10,000;  polynuclears  normal.  At  end  of  nine 
days,  on  subsidence  of  symptoms,  appendectomy  by  the  late  Frank  Hartley. 
The  base  of  the  appendix  and  about  2  inches  of  the  body  .was  firmly  bound 
to  the  cecum,  lying  almost  vertical.  There  was  then  an  acute  bend 
(right  angle),  and  about  ly^  inches  pointed  out  free  into  the  abdominal 
cavity  toward  the  median  line.  The  appendix  lay  high  up.  The  tip 
was  bulbous,  contained  two  small  concretions,  and  the  e  was  a  small 
superficial  ulceration.  With  an  acute  attack,  perforation  and  general 
peritonitis  would  have  resulted. 

Blood  Clotting  Time. — In  connection  with  a  case  of  chronic  appendi- 
citis the  writer  had  an  interesting  and  suggestive  experience.  The  patient 
was  a  young  girl  of  sixteen.  There  was  no  history  of  "bleeders"  in  the 
family,  nor  had  the  patient  ever  had  such  symptoms.  She  was  operated 
on  by  Alfred  S.  Taylor  at  the  New  York  Hospital.  On  separating 
appendical  adhesions,  marked  oozing  and  at  several  points  considerable 
bleeding  occurred.  The  hemorrhage  was  stopped  with  some  difficulty, 
it  being  necessary  to  sew  with  fine  catgut  at  one  point.  After  operation 
a  Murphy  drip  containing  5 1  calcium  lactate  was  begun.  The  blood 
was  tested  and  blood-clotting  time  was  found  to  be  twelve  minutes, 
markedly  delayed.  Lactate  of  calcium  gr.  60  with  gelatin  were  given 
daily  and  by  the  end  of  five  days  blood-clotting  was  normal.  The  cause 
of  her  condition  could  not  be  determined.  The  writer  believes  that 
it  is  in  this  type  of  case,  with  poor  blood-clotting,  that  may  produce 
"pulmonary  embolism."  The  blood-clotting  time  should  he  tested  before 
every  operation. 

Chronic  appendicitis  is  the  type  where  palpation  by  Edebohl's  method 
is  safe  and  of  value,  and  where  at  times  the  enlarged  appendix  can  be 
appreciated. 

The  patient  lies  on  his  back  with  the  thighs  flexed,  and  the  examiner, 
placing  three  or  four  fingers  of  the  right  hand,  palm  side  downward, 
draws  them  over  the  abdomen  from  the  umbilicus  to  the  anterosuperior 
spine  of  the  ileum,  exerting  considerable  pressure.  The  appendix  can 
be  recognized  as  a  firm  cord.  Morris  reinforces  this  hand  with  the 
three  fingers  of  the  left  hand.  Gentle  palpation  by  the  following  method 
is  often  preferable  (Morris):  First  seek  the  ascending  colon  as  a  land- 
mark. It  is  palpated  by  pressing  the  three  fingers  of  the  left  hand  gently 
beneath  the  right  rectus  muscle  on  a  plane  above  the  navel,  and  then 


824 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


drawing  the  fingers  away  so  that  the  colon  sHps  out  from  beneath  them. 

Second,  follow  this  landmark  down  until  the  cecum  is  reached.     Gently 

indent  the  abdominal  wall  with  these  fingers  at  the  site  of  the  appendix. 

With  the  other  hand  on  the  other 

side  of  the  abdomen,  press  back 

and  forth,  so  the  cecum  is  carried 

back  and  forth  beneath  the  fingers. 

If    this    fails,    press    the    feeling 

fingers  beneath  the  inner  edge  of 

the  cecum,  so  the  latter  will  be 

lifted  over   their  tips  and  make 

lateral  pressure  on   the  opposite 

side  as  before. 

It  has  been  at  times  recom- 
mended to  examine  with  the  pa- 
tient standing  erect  or  bending 
slightly   forward,  but  the  dorsal  | 

posture  is  preferable. 

In  the  chronic  cases  there  is 


Fig.  327. — An  appendix  which  was 
quite  normal  in  external  appearance, 
but  it  felt  harder  than  normal  on  pal- 
pation, and  longitudinal  section  shows 
the  inner  coats  to  have  been  replaced 
by  connective  tissue,  with  total  oblitera- 
tion of  the  lumen.  The  patient  had 
suffered  from  occasional  attacks  of  pain 
in  the  appendical  region,  and  from  in- 
testinal dyspepsia,  both  of  which  dis- 
appeared on  removal  of  the  appendix 
(Morris). 


Fig.  328. — Two  appendices  in  which 
all  structures  had  practically  been  re- 
placed by  connective  tissue,  but  enough 
nerve-filaments  had  remained  to  cause 
persistent  intestinal  dyspepsia,  for 
which  the  patients  had  received  treat- 
ment by  authorities  without  perma- 
nent result,  until  the  appendices  were 
removed.  Both  patients  then  became 
well  (Morris). 


generally    no     temperature    unless    subacute    or    acute    exacerbations 
occur. 

Protective  Appendicitis  or  Harmful  Involution  of  the  Appendix. — 
Symptoms  of  harmful  involution  of  the  appendix  (Morris): 


APPENDICITIS  825 

I.  Symptoms  of  auto-intoxication  with  attacks  of  headache,  nervous- 
ness, poor  appetite,  etc.  2.  Chronic  intestinal  dyspepsia.  3.  Discomfort  in 
the  appendical  region.  4.  An  appendix  f  eeUng  hard  and  narrow  on  palpation. 
5.  Hyperesthesia  of  the  right  lumbar  pleuxs  (tenderness  at  Morris'  point.) 

There  are  persistent  distention  of  the  cecum  and  ascending  colon, 
with  gas  and  a  sensation  of  discomfort  in  the  appendical  region.  In 
some  cases  there  may  be  acute  local  pain  and  tenderness,  but  not  enough 
to  send  the  patient  to  bed.  They  are  rather  apt  to  stay  up  and  about  on 
account  of  their  general  irritability.  In  others  there  is  merely  a  sensation 
of  warmth  in  the  appendical  region,  which  fluctuates  in  intensity  from 
day  to  day  and  may  be  sometimes  absent.  In  Figs.  327,  328  are  depicted 
three  appendices  which  were  removed  for  this  condition.^  The  patient 
has  a  tendency  to  press  upon  the  abdomen  at  that  point  or  to  lean  against 
a  table.  The  sensation  may  pass  away  for  a  few  hours  or  days,  but 
tends  to  recur  and  last  for  years. 

On  palpation  the  involution  appendix  feels  narrow  and  hard.  There 
is  no  history  of  acute  or  chronic  appendicitis.  The  type  generally  occurs 
in  those  over  twenty-five  or  thirty  years  of  age. 

Diagnosis. — Acute  Appendicitis. — Abdominal  pain,  becoming  localized 
in  the  right  iliac  fossa;  tenderness  at  McBurney's  point;  rigidity  of  the 
right  rectus;^  temperature;  rapid  pulse;  gastro-intestinal  disturbances; 
in  some  cases  the  presence  of  tumefaction  and  in  others  the  subsequent 
development  of  peritonitis — are  all  diagnositc  of  acute  appendicitis. 
In  addition,  there  are  the  differential  leukocyte  count  and  hyperinosis, 
which  are  an  aid  to  diagnosis  in  acute  cases. 

Chronic  Appendicitis. — There  is  slight  tenderness  or  feeling  of  dis- 
comfort at  McBurney's  point  and  at  times  under  deep  pressure  the  en- 
larged appendix  can  be  felt  beneath  the  fingers.  Morris'  point  may  also 
be  tender.  When  there  is  no  tenderness  at  McBurney's  point,  it  may 
be  found  at  Morris'  point  due  to  mucus  inclusion  or  scar  tissue  after  an 
acute  attack.  Fibroid  degeneration  of  the  appendix  also  gives  tender- 
ness at  Morris'  point.  Neglect  to  palpate  the  latter  point,  because  McBurney^s 
point  is  not  tender,  is  the  most  frequent  cause  of  failure  to  detect  chronic 
appendical  trouble.  On  the  other  hand  some  patients  complain  of  gas- 
tric or  intestinal  disturbance  and  have  never  noted  pain  or  tenderness  in 
the  appendical  region,  but  palpation  of  McBurney's  or  Morris'  points  •mill 
demonstrate  a  sensitive  appendix. 

X-ray  Diagnosis  of  Appendicitis. — This  is  contraindicated  in  acute 
and  subacute  cases.  Chronic  cases  of  appendicitis  the  writer  believes  can 
be,  as  a  ride,  easily  diagnosed  without  the  use  of  the  x-rays,  but  they  have 
their  uses  in  many  cases.  One  must  remember  that  the  fibrous  condition 
may  be  so  marked  that  the  entrance  to  the  appendix  may  be  shut  off  and 
no  bismuth  be  able  to  enter  the  chronically  inflamed  appendix.  In  some 
cases  with  retroverted  adherent  appendix,  it  can  at  no  time  be  detected. 
In  normal  cases  with  a  tight  valve,  bismuth  often  may  not  enter.  With 
a  chronic  appendicitis  with  interstitial  inflammation,  motility  of  the 
appendix  would  be  disturbed  and  there  would  be  a  retention  of  bismuth 

^  Protective  Appendicitis,  pp.  99-103.     Dawn  of  the  Fourth  Era  in  Surgery  (Morris). 
2  The  lower  segment  of  the  rectus  is  rigid,  unless  the  appendix  is  retroverted,  when 
the  rigidity  extends  further  upward. 


826  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

in  the  appendix  beyond  normal  length  of  time.  The  radiologists  base 
their  diagnosis  chiefly  on  this  feature  and  also  on  the  evidences  of  dis- 
tortion, angulations  and  adhesions  of  the  appendix.  Many  of  them 
employ  fluoroscopy  as  well  as  radiograph.  The  radiographs  the  writer 
believes  the  most  valuable,  as  error  of  interpretation  is  less  likely  with 
the  pictures.  When  the  appendix  is  demonstrable  by  the  radiograph,  one 
can  determine  its  size,  position  and  evidence  of  angulation,  adhesions  or 
the  presence  of  a  concretion. 

First  in  importance  are  the  physical  examination  and  clinical  symptoms. 

Six  hours  or  more  after  administration  of  the  barium  or  bismuth  meal 
one  can  often  determine  the  appendix.  If  the  colon  is  entirely  free  from 
bismuth  in  two  days,  but  bismuth  retention  still  continues  in  the 
appendix,  I  should  consider  the  motility  of  the  appendix  diminished  and 
in  connection  with  local  tenderness,  diagnose  a  chronic  appendicitis. 

Evidences  of  angulation  or  adhesions  with  local  tenderness  would  cause 
one  to  arrive  at  the  same  conclusion. 

Stasis  of  the  caput  coli  and  ascending  colon  frequently  occur  in  con- 
nection with  adhesions  from  chronic  appendicitis.  It  may  be  present  with 
Jackson's  membrane.  It  is  advisable  also  to  radiograph  after  a  barium 
or  bismuth  enema,  which  aids  in  the  determination  of  Lane's  kink  with 
adhesions  near  the  ileocecal  valve  and  also  of  adhesions  of  the  colon. 

The  particular  value  of  the  x-rays  in  chronic  appendicitis  in  my  opinion, 
is  not  to  determine  the  appendicular  condition,  but  the  qiiestion  o/ adhesions 
about  the  cecum  and  ascending  colon,  in  which  event  a  longer  incision  would 
be  required  than  the  minute  one  usually  employed.  When  there  are  gastric 
symptoms  with  chronic  appendicitis  suggestive  of  ulcer,  additional  radio- 
graphs of  the  stomach  and  duodenum  are  indicated.  Spasm  of  the  pylorus 
or  cap  may  be  demonstrated  or  even  the  radiographic  appearances  of  ulcer. 

Differential  Diagnosis. — Renal  colic  with  calculus  impacted  in  the  right 
ureter  may  simulate  appendicitis,  but  there  are  the  history  of  acute  pain 
in  the  kidney,  burning  sensation  of  the  urine,  and  drawing  up  of  the  right 
testicle,  with  sand,  gravel,  or  blood,  etc.,  in  the  urine.  The  x-xdiy  may 
give  information.  Movable  cecum  has  been  mistaken  for  appendicitis. 
With  movable  cecum^  there  is  local  distention  (tympanites)  of  the  cecum, 
and  the  condition  is  usually  associated  with  enteroptosis  and  its  symp- 
toms.    Symptoms  are  not  acute. 

With  Dietls'  crisis  there  are  the  movable  kidney,  the  history  of  the 
attack,  and  the  kidney  is  swollen  and  sensitive. 

In  intestinal  colic  the  pain  is  relieved  after  passage  of  flatus. 

In  biliary  colic  the  pain  radiates  to  the  back  and  up  to  the  right 
shoulder,  usually  with  a  previous  history  of  gall-stones,  etc. 

In  perforation  of  the  gall-bladder,  or  duodenum  the  contents  gravitate 
toward  the  appendix;  and  this  possibility  must  always  be  considered  in 
apparently  acute  perforative  appendicitis.  In  these  cases  the  sud- 
den acute  pain  occurs  in  the  epigastrium  and  right  hypochondrium 
and  there  is  the  previous  history  pointing  to  duodenal  ulcer,  or  to  gall- 
bladder disease.  Osier,  in  the  Johns  Hopkins  Bulletin,  July-August, 
1904,  in  an  article  entitled  "The  Surgical  Importance  of  the  Visceral  Crises 
^  The  a;-rays  show  the  misplaced  cecum. 


APPENDICITIS  827 

in  the  Erythema  Group,"  calls  attention  to  the  fact  that  abdominal  pain 
in  the  erythema  group  occurs  in  angioneurotic  edema;  with  simple 
urticaria;  with  Henoch's  purpura;  with  erythema  multiforme,  and  in 
other  conditions  in  which  skin  lesions  only  occur  late  in  the  disease. 
Musser,  in  Amer.  Med.,  March,  1904,  reported  cases.  Osier  describes 
purpura,  various  types  of  erythema,  urticaria,  and  angioneurotic  edema 
with  visceral  lesions  in  his  Practice  of  Medicine.  A.  B.  Johnson^  reports 
cases  of  Henoch's  purpura  with  initial  abdominal  symptoms,  colic, 
pain,  rigidity,  vomiting,  temperature,  leukocytosis,  etc.,  the  cases  closely 
mimicking  acute  appendicitis.  In  fact,  until  the  eruption  and  joint  lesions 
appeared,  diagnosis  was  impossible.  The  writer  in  the  Symposium  on 
Acidosis  in  American  Medicine,  summer  of  191 6,  reports  a  case  of  acidosis 
and  indicanuria  with  angioneurotic  edema  of  the  cecum  and  ascending 
colon,  simulating  appendicitis.  In  women  the  differential  diagnosis 
between  an  inflamed  low  appendix  and  salpingitis  is  sometimes  difficult, 
as  they  frequently  are  associated. 

Tenderness  of  both  lumbar  ganglia,  however,  shows  pelvic^  trouble, 
and  when  the  hypersensitiveness  is  greater  on  the  right  side,  that  the 
appendix  and  tubes  are  both  diseased;  with  salpingitis,  there  is  no  tender- 
ness at  McBurney's  point  with  the  patient  on  the  left  side. 

Malaria  may  occasionally  give  abdominal  symptoms  simulating 
appendicitis.     Brickner^  reports  some  interesting  cases. 

With  pneumonia,  especially  central  near  the  right  base,  and  with 
diaphragmatic  pleurisy,  there  is  occasionally  in  the  early  stages  pain 
transferred  to  the  right  iliac  fossa,  and  mistaken  for  appendicitis.  This 
possibility  must  be  considered.  The  physical  examination  of  the  lungs 
and  pulmonary  symptoms  should  be  carefully  observed.  Determination 
of  Head's  zones  is  of  value;  the  zone  for  the  lungs  is  from  the  first  to  the 
ninth  dorsal  segment,  chiefly  the  third,  fourth,  and  fifth,  which  give 
hyperalgesia  over  the  thorax.  With  appendicitis  hyperalgesia  is  below 
the  umbilicus. 

Hyperesthesia  of  the  right  lumbar  ganglia  is  absent  in  pneumonia 
without  involvement  of  the  appendix.  In  other  words,  no  hypersen- 
sitiveness of  the  right  lumbar  ganglia  on  deep  pressure,  then  no  appendi- 
citis.    Look  for  inflammation  elsewhere  according  to  Morris. 

Myalgia. — Rarely  from  exposure,  there  maybe  inflammation  or  myalgia 
of  one  of  the  abdominal  muscles.  If  the  right  rectus  is  affected  in  lower 
quadrant,  one  might  suspect  appendicitis.  There  may  even  be  a  slight 
rise  of  temperature  and  mild  leukocytosis.  Lateral  pressure  on  the 
rectus,  for  example,  gives  pain,  and  a  sharp  tap  on  the  muscle  (superficial 
pressure)  over  its  tendinous  attachment  will  cause  more  pain  than  deep 
pressure.  There  are  often  muscular  rheumatic  pains  elsewhere.  In 
addition  the  patient  does  not  look  ill. 

In  typhoid  fever  there  may  be  pain  in  the  right  iliac  fossa  and  appen- 
dicitis is  often  a  complication. 

In  simple  typhoid  there  is  no  leukocytosis,  but  leukopenia. 

'  Conditions  Simulating  Appendicitis,  N.  Y.  State  Jour,  of  Med.,  March,  1910. 
2  The  New  Point  in  Diagnosis  Between  Appendicitis  and  Tubal  Disease  (Morris), 
Amer.  Jour,  of  Obstet.,  1909,  vol.  Ix,  No.  5. 
^  Archives  of  Diagnosis,  April,  1913.  j 


828  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

In  typhoid  with  appendicitis,  in  addition  to  the  right  iliac  pain  and 
tenderness,  the  presence  of  leukocytosis,  increased  polynuclears,  and 
hyperinosis  make  the  diagnosis  of  appendicitis.  Luckett^  has  reported  a 
case  of  torsion  of  the  greater  omentum  complicated  by  acute  appendicitis, 
in  which  the  diagnosis  of  acute  appendicitis  with  probable  abscess  was 
apparently  justified  by  the  symptoms.  This  is  an  interesting  possibility 
to  remember.  Seminal  vesiculitis  may  simulate  a  chronic  appendicitis 
and  rectal  examination  aids  in  differentiation. 

As  an  aid  to  differential  diagnosis  in  affections  of  the  viscera,  the 
determination  of  Head's  zones  (cutaneous  hyperalgesia)  is  of  value. 
This  is  especially  true,  I  believe,  in  the  differentiation  of  appendicitis  from 
the  conditions  to  which  I  have  just  referred.  Head  found  that  in  many 
visceral  affections,  if  the  sensitiveness  of  the  skin  was  tested  by  running  a 
pin  point  over  the  cutaneous  surface,  there  could  be  shown  to  exist  areas 
over  which  there  was  a  more  or  less  hypersensitiveness  to  pain.  These 
areas  were  constant  and  distinct,  could  be  mapped  out  on  the  surface  of 
the  skin,  and,  when  present,  were  almost  an  infallible  sign  of  an  affection 
of  the  organ  to  which  they  corresponded.  The  skin  tenderness  was 
sup>erficial  and  extended  over  definite  areas  which  never  overlapped  one 
another.  Each  area  or  zone  of  hyperalgesia  had  a  "maximum  region" 
which  often  corresponded  to  the  seat  of  pain.  These  areas  were  sen- 
sitive to  heat  and  cold,  but  not  to  simple  touch. 

The  areas  corresponded  to  segments  of  the  spinal  cord,  not  to  the  dis- 
tribution of  peripheral  nerves  or  spinal  nerve-roots.  The  zones  were 
named  according  to  the  segments  of  the  cord:  cervical,  i  to  7;  dorsal, 
I  to  12;  lumbar,  i  to  5;  sacral,  i  to  4.  They  were  broader  in  front  at  the 
median  line,  narrowed  at  the  side  of  the  body,  and  again  broaden  out 
near  the  spinal  column.  The  zones,  as  a  rule,  never  extend  beyond  the 
median  line  in  front  or  behind.  Head  gives  the  following  zones  for  the 
abdominal  viscera. 

Stomach,  sixth,  seventh,  eighth,  and  ninth  dorsal.  Cardiac  end, 
sixth  and  seventh  dorsal,  right.     Pyloric  end,  eighth  and  ninth  dorsal,  left. 

Liver,  eight,  ninth,  and  tenth  dorsal,  right. 

Gall-bladder,  eighth  and  ninth  dorsal,  right. 

Intestines,  ninth,  tenth,  eleventh,  and  twelfth  dorsal. 

Colon,  ninth,  tenth,  and  eleventh  dorsal. 

Cecum  and  appendix  vermiformis,  tenth  and  eleventh  dorsal,  right. 

Kidney,  tenth  dorsal,  sometimes  eleventh  dorsal. 

Ureter,  eleventh  and  twelfth  dorsal,  first  lumbar. 

Bladder  (first?),  second,  third,  and  fourth  sacral. 

Uterus,  tenth,  eleventh,  and  twelfth  dorsal,  first  lumbar. 

Appendages,  eleventh  and  twelfth  dorsal,  first  lumbar. 

Head  first  tested  sensitiveness  to  pain  by  pinching  up  folds  of  skin 
and  later  by  stroking  the  skin  with  the  point  of  a  sharp  pin.  Elsberg^ 
and  Neuhof  suggest  the  following  method  of  examination : 

"A  sharp  pin  is  held  between  the  thumb  and  index-finger  of  the 
right  hand,  the  nail  of  the  index-finger  resting  on  the  patient's  skin. 

*  Jour.  Amer.  Med.  Assoc,  April  23,  1910. 
2^mer.  Jour.  Med.  Sci.,  Nov.,  1908. 


APPENDICITIS  829 

The  pin  is  then  made  to  traverse  slowly  the  surface  of  the  skin,  care 
being  taken  that  the  nail  of  the  index-finger  presses  equally  along  the 
area  examined.  The  patient  is  instructed  to  say  'now'  as  soon  as  the 
pin  stroke  becomes  painful. 

"In  examining  the  skin  of  the  abdomen  for  hyperalgesic  areas,  the 
pin  traverses  the  abdomen  from  side  to  side  and  from  above  down- 
ward; the  points  at  which  the  patient  complains  of  pain  are  marked. 
In  this  manner  it  is  possible  to  map  out  areas  on  the  skin,  and  when 
such  an  area  has  been  found,  the  pin  is  made  to  approach  it  from  all 
sides,  so  that  its  form  and  position  can  be  determined.  Care  must  be 
taken  that  the  pressure  of  the  pin  point  remains  constantly  the  same, 
especially  as  the  pin  passes  over  the  groin  and  slips  off  the  costal  border  or 
over  the  crest  of  the  ileum. 

"After  the  zone  has  been  thus  mapped  out  on  the  skin  the  proced- 
ure is  repeated  a  second  time,  and  now  it  is  a  good  plan  for  the  operator 
to  control  both  patient  and  himself  by  keeping  both  the  patient's  and 
his  own  eyes  away  from  the  pin. 

"The  hyperalgesia  is  sometimes  so  marked  that  the  patient  will 
shrink  or  cry  out  as  soon  as  the  border  of  the  zone  is  reached.  In  very 
young  children  the  examination  is  useless,  but  older  children  will  give 
correct  answers. 

"If  the  examination  is  carried  out  in  the  manner  above  described 
it  will  be  possible,  in  a  large  number  of  patients  with  visceral  affections, 
to  map  out  areas  of  hyperalgesia  extending  from  the  median  line  in  front 
to  the  spines  behind.  The  *  maximum'  areas  can  often  be  mapped  out 
lying  within  the  boundaries  of  the  zones;  sometimes  only  the  'maxima' 
are  present.     Sometimes  several  'maxima'  are  found  in  one  zone." 

The  zones  appear  early  in  the  course  of  visceral  affections,  and  fre- 
quently persist  throughout.  They  have  been  reported  as  appearing  very 
early;  for  example,  in  the  commencement  of  acute  appendicitis,  while 
the  pain  was  still  in  the  epigastric  region  and  there  was  no  local  tenderness 
at  McBurney's  point,  the  zone  for  the  appendix  was  discovered.  Shortly 
after  the  typic  symptoms  appeared.  One  must  remember  the  following 
(Elsberg) : 

1.  The  characteristic  zone  may  appear  after  palpation  of  the  diseased 
organ. 

2.  The  hyperalgesic  zone  will  not  appear  on  examination  until  fifteen 
to  thirty  minutes  have  elapsed  after  removal  of  the  ice-bag  or  hot-water 
bag,  if  such  have  been  applied. 

3.  The  disappearance  of  the  zone,  as  a  rule,  follows  relief  of  the 
lesion  of  the  affected  viscus. 

4.  The  zones  may  disappear  temporarily  after  repeated  examina- 
tions in  close  succession.     Later  they  reappear. 

5.  The  disappearance  of  the  zone,  together  with  persisting  or  in- 
creasing symptoms,  is  probably  a  sign  of  ill  omen. 

6.  The  zones  are  not  invariably  present.  While  the  absence  of  a 
characteristic  zone  in  a  suspected  affection  of  an  abdominal  organ  does 
not  mean  that  there  may  not  be  disease  of  that  organ,  the  presence  of  the 
zone  means  that  there  is  an  undoubted  lesion.     From  this  one  must  not 


830  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

conclude  that  the  viscus  which  gives  the  zone  is  the  one  which  causes  all 
the  symptoms,  for  we  may  get  a  zone  from  an  organ  which  is  secondarily 
affected. 

7.  The  presence  of  areas  of  skin  hyperalgesia  corresponding  to  several 
viscera  may  mean  a  combined  lesion  of  several  adjoining  viscera,  although 
it  may  occasionally  mean  disease  of  the  spinal  cord  itself. 

8.  The  presence  of  a  Head  zone  alone  must  not  be  the  only  factor 
in  arriving  at  a  diagnosis,  but  it  must  be  used  in  conjunction  with  other 
signs  and  symptoms.  When  one  is  in  doubt  as  to  which  of  several  viscera 
is  the  seat  of  the  lesion,  the  presence  of  the  characteristic  zone  has  been  an 
aid;  for  example,  in  differential  diagnosis  between  appendicitis  (with 
retroverted  appendix)  and  kidney  and  gall-bladder  disease,  or  between 
appendicitis  and  salpingitis.  It  seems  preferable  to  adopt  Elsberg's 
method  and  speak  of  the  zones  by  the  names  of  the  viscera  to  which  they 
belong.  The  position  of  his  zones  vary  a  trifle  from  Head's,  and  are 
as  follows: 

Thus,  the  stomach  zone  corresponds  to  the  seventh,  eighth,  and 
ninth  segments  of  Head  (according  to  Head,  sixth,  seventh,  eighth, 
and  ninth);  the  gall-bladder  zone,  to  the  eighth  and  ninth  segments  on 
the  right  side  (same  as  Head's  diagrams);  the  appendix  zone,  to  the 
tenth  and  eleventh  segments  of  Head  r>n  the  right  side.  It  will  be  found, 
in  the  description  of  the  zones,  that  the  limit  of  the  posterior  portions 
is  not  absolute.  Thus,  in  describing  the  gastric  zone,  that  it  extends 
from  the  sixth  to  the  tenth  vertebrae  approximately.  The  zones,  except 
the  gastric  zone,  stop  sharply  at  the  posterior  median  line,  but  their 
upper  and  lower  margins  are  more  variable. 

The  zone  appears  on  that  side  of  the  body  on  which  the  afected  organ 
has  its  nervous  connections,  the  side  on  which  the  organ  is  normally  situated. 
If  an  organ  belongs  on  the  left  side,  the  hyperalgesic  zone  will  be  found  on 
that  side,  even  if  the  organ,  through  disease  or  mobility,  lies  on  the  other 
side  of  the  body. 

Those  areas  are  called  "objective  zones"  when  the  patient  suffers 
actual  pain  as  the  stroking  pin  enters  them.  All  less  painful  zones  will 
be  called  ''subjective  zones."  By  an  "anterior  zone"  we  mean  an 
anterior  maximal  area;  by  a  "posterior  zone,"  a  posterior  maximal  area. 

The  Stomach. — ^The  complete  gastric  zone  was  found  to  be  uncommon. 
It  extended  as  a  broad  belt  all  around  the  body.  At  times  only  a  portion 
of  it  showed  on  examination. 

In  the  median  line  in  front  it  extends  from  the  xiphoid  almost  to 
the  navel;  it  then  passes  upward  and  backward  on  both  sides  toward 
the  spine,  where  it  extends  from  the  sixth  to  the  tenth  vertebra  (ap- 
proximately). Incomplete  zones  are  more  frequent,  either  an  anterior 
portion  extending  to  the  right  or  to  the  left,  or  on  both  sides  of  the  anterior 
median  line. 

In  Figs.  329  and  330  the  various  zones  are  depicted  on  the  anterior  and 
posterior  surfaces  of  the  body. 

The  Duodeniun. — The  duodenal  zone  lies  between  the  gall-bladder 
and  the  appendix  zones.  It  lies  almost  completely  to  the  right,  but 
occasionally  extends  slightly  to  the  left  of  the  anterior  median  line. 


APPENDICITIS 


831 


Anteriorly  it  is  broad;  its  upper  limit  is  about  on  a  horizontal  line  midway 
between  the  umbilicus  and  the  ensiform  cartilage;  its  lower  border  is  a 
little  below  the  umbilicus.  It  extends  backward  and  slightly  upward, 
and  narrows;  at  the  anterior  axillary  line  it  is  very  narrow  (about  13^ 
inches);  it  then  becomes  broader,  and  is  lost  about  the  midscapular  line. 
It  corresponded  roughly  to  the  ninth  dorsal  zone  of  Head. 

With  a  perforating  duodenal  ulcer,  intestinal  contents  gravitate  to  the 
appendical  region.  If  the  ulcer  was  occult,  differential  diagnosis  from 
appendicitis  may  be  difficult.  Presence  of  the  typic  zone  may  prove  of 
assistance. 

Gall-bladder  and  Liver. — This  zone  is  present  in  acute  affections 
of  the  gall-bladder  more  often  than  in  any  other  acute  intra-abdominal 


Qcdl  Bladder 


Cecum  and 
Appendix 

Ovary  and  Tube 


Fig.  329. — Head's  zones.  The  general  location  and  outline  of  the  zones  of  cutane- 
ous hyperalgesia  for  some  of  the  abdominal  viscera.  Anterior  view.  The  maxima 
are  deeply  shaded.  Only  the  left  half  of  the  gastric  zone  is  given.  The  ureteral  zone 
consists  of  a  series  of  maxima  (diagrammatic)  (Elsberg  and  Xeuhof). 


affection.  In  these  cases  the  Head  zone  has  often  been  a  valuable  diag- 
nositc  aid.  In  many  cases  an  enlarged,  tender,  and  palpable  gall- 
bladder makes  the  diagnosis  easy,  but  the  recognition  of  the  disease  is 
often  difficult  or  impossible  in  stout  patients  without  jaundice,  with 
marked  abdominal  distention  and  rigidity.  These  patients  may  refer 
their  pain  to  the  right  lower  abdomen,  and  may  have  their  tenderness  in 
this  region.  Acute  intestinal  obstruction,  acute  pancreatitis,  or  acute 
appendicitis  are  the  diagnoses  often  made.  In  some  patients  the  pre- 
sence of  a  zone  of  hyperalgesia  has  been  the  only  localizing  sign. 


832 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


The  gall-bladder  zone  lies  in  the  right  half  of  the  abdomen,  above 
the  level  of  the  umbilicus.  The  complete  zone  starts  exactly  at  the 
median  line  in  front,  extending  from  some  distance  below  the  xiphoid 
to  a  short  distance  above  the  navel.  Tracing  it  backward,  it  slants 
obliquely  upward  and  becomes  narrow,  passing  partly  over  and  partly 
below  the  costal  arch.  It  is  narrowest  at  the  midaxillary  line,  where 
it  is  about  2  inches  wide.  Posteriorly  it  becomes  broader,  and  at  the 
spines  it  is  about  as  wide  as  in  front.  In  some  cases  more  or  less  of 
the  anterior  portion  only  has  been  present  (maximal  area). 

Kidney  and  Ureter. — The  kidney  zone  is  wide  at  the  posterior  median 
line,  where  it  begins,  and  gradually  narrows  anteriorly.     Its  greatest 


10th  Dorsal  Spine 


1st  Sacral 


Fig.  330. — Head's  zones.     The  general  location  and  outline  of  the  posterior  parts 
of  the  zones  (diagrammatic)   (Elsberg  and  Neuhof). 


breadth  is  at  the  spinal  column.  It  narrows  to  make  a  triangular  area, 
with  a  rounded  apex,  situated  a  little  to  that  side  of  the  anterior  median 
line  on  which  the  zone  lies.  It  never  quite  reaches  the  anterior  median 
line.  Each  zone  is  strictly  limited  to  its  half  of  the  body.  There  is  no 
difference  in  contour  between  the  right  and  left  kidney  zones.  The 
kidney  zones  are  complicated  by  the  additional  ureteral  zones  that  are 
present  in  certain  cases.  The  ureteral  zone  springs,  so  to  speak,  from  the 
lower  margin  of  the  kidney  zone  at  the  anterior  axillary  line.  In  an 
average  adult  it  is  about  3  inches  wide  at  its  beginning.  It  narrows 
in  its  downward  course,  and  passing  obliquely  downward  and  forward, 
it  terminates  on  its  side  of  the  penis  and  scrotum  in  the  male;  the  labia 


APPENDICITIS  ,  833 

in  the  female.  After  the  first  narrowing  it  widens  again  well  below  the 
umbilical  level.  In  the  male,  it  can  be  ascertained  that  the  zone  spreads 
fan  shape  to  the  anterior  median  line  over  the  pubic  area  and  its  half  of 
the  scrotal  and  penile  skin.  There  are  anterior  and  posterior  kidney 
maximal  areas.  The  ureteral  zone  seems  to  be  made  up  of  a  series  of 
maxima.  The  kidney  and  ureteral  zone  is  most  often  present,  as  in  the 
other  intra-abdominal  affections,  in  the  presence  of  pain  and  tenderness. 

In  the  differential  diagnosis  of  septic  infarction  of.  the  kidney,  pyelo- 
nephritis, etc.,  from  retroverted  appendix  (appendicitis),  determination 
of  the  kidney  zone  is  of  value,  taken  in  connection  with  Brewer's  point 
(tenderness  at  the  costovertebral  angle),  urinary  analysis,  etc.  (author). 

Vermiform  Appendix. — The  zone  begins  at  the  median  line  in  front, 
sometimes  a  little  to  its  left,  from  a  point  a  short  distance  below  the 
umbilicus  to  one  equally  distant  from  the  symphysis  pubis.  It  narrows 
toward  the  anterior  axillary  line  to  a  width  of  about  2  inches  (average 
adult).  From  this  line  it  widens  and  spreads  to  the  posterior  median 
line  from  the  eleventh  dorsal  to  the  second  lumbar  spines  (approximately). 
At  the  anterior  median  line  there  is  often  a  tongue-like  downward  ex- 
tension of  the  zone  (Fig,  329-330).  There  is  an  anterior  maximal  area 
which  is  sometimes  present  alone.  It  may  be  that  the  "appendix" 
zone  is  really  an  "appendix  and  cecum"  zone,  because  the  cecum  is  so 
frequently  involved  in  appendicitis.  Sometimes,  when  an  ice-bag  has  been 
employed  over  the  appendix  region,  only  the  posterior  half  of  the  zone  is 
present. 

Diagnosis  has  been  aided  in  a  considerable  number  of  the  patients 
by  the  presence  of  the  zone,  especially  in  that  large  class  of  acute  cases 
in  which  the  abdomen  is  rigid  and  there  is  no  palpable  mass.  The  zone 
has  been  of  the  greatest  value  in  helping  to  differentiate  between  diseases 
of  the  appendix  and  those  of  the  gall-bladder  or  right  uterine  adnexa. 

The  absence  of  a  zone  is  of  no  significance.  If  a  patient  complains 
of  symptoms  which  resemble  appendicitis,  and  a  zone  is  not  present  in 
the  right  lower  abdomen,  it  is  well  to  look  elsewhere  for  hyperalgesia. 
Thus  in  cases  of  beginning  pneumonia  that  had  considerable  pain,  tender- 
ness, and  rigidity  in  the  right  iliac  region,  the  presence  of  hyperalgesia  over 
the  thorax  first  lead  to  careful  examintion  of  tJie  lungs. 

Intestines. — Head  gives  the  zone  as  corresponding  to  the  ninth, 
tenth,  eleventh,  and  twelfth  dorsal  segments  of  the  spine.  Elsberg 
does  not  find  these  uniform.  He  shows,  howeVer,  uniform  zones  in 
ileocecal  tuberculosis  and  in  perforation  of  the  ileum. 

Ileocecal  Tuberculosis. — There  is  a  large  area  of  hyperalgesia  occupy- 
ing the  whole  right  lower  abdomen  down  to  Poupart's  ligament,  often 
extending  a  little  to  the  left  of  the  median  line,  and  posteriorly  becoming 
lost  about  the  posterior  axillary  line. 

Perforation  of  the  Ileimi. — The  zone  resembles  that  of  ileocecal  tuber- 
culosis, but  extends  more  to  the  left  of  the  median  line. 

Uterus  and  Adnexa. — Head  describes  differences  between  the  zones 

for  the  uterus,   the  ovary,  and  the  tube.     Elsberg  differs  somewhat: 

The  zone  for  the  right  adnexa  lies  on  the  right  half  of  the  median  line; 

that  of  the  left  adnexa  on  the  left  half;  the  zone  for  the  uterus  is  a  com- 

53 


$34  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

bination  of  the  two.  There  is  no  difference  between  the  zones  for  the 
right  and  left  adnexa.  Beginning  some  distance  above  Poupart's  liga- 
ment, the  upper  margin  of  the  zone  runs  parallel  to  it,  and  pursues  this 
obliquely  upward  course  to  the  spine  of  the  second  lumbar  vertebra 
(approximately).  The  lower  margin  is  a  long,  tongue-like  process  that 
extends  half-way  down  the  thigh  on  its  inner  aspect.  The  lower  margin, 
as  it  passes  a  short  distance  below  the  anterior-superior  spine  of  the 
ileum,  approaches  the  upper,  the  average  breadth  of  the  zone  here  being 
3  inches.  The  lower  border  then  passes  horizontally  backward  over 
the  buttock  to  reach  the  posterior  median  line  partly  over  the  sacrum. 
Sometimes  the  upper  half  of  this  zone  is  better  developed,  sometimes 
the  lower;  these  may  be  considered  maxima. 

Diagnosis  in  the  diseases  of  the  uterus  has  not  been  aided  by  the 
presence  of  a  zone.  Elsberg  states  that  in  about  half  of  the  cases  of 
dysmenorrhea  and  of  endometritis  with  pain,  the  zone  was  present. 
Some  of  the  cases  of  retroflexion,  retroversion,  anteflexion,  and  prolapse 
showed  the  zone.  It  was  present  in  the  five  cases  of  uterine  polyp  that 
he  observed  (all  of  them  had  pain).  It  was  not  present  in  tumors  of 
the  uterus,  except  in  a  few  cases. 

In  diseases  of  the  tubes  and  ovaries,  especially  those  of  the  right 
side,  the  zones  have  been  of  diagnostic  value. 

I  can  substantiate  these  observations  of  Elsberg  and  Neuhof,  and 
believe  that  the  tests^  for  Head's  zones  are  a  valuable  aid  in  differential 
diagnosis,  especially  in  appendicitis. 

Prognosis. — There  is  always  an  element  of  uncertainty  in  every  case 
of  appendicitis,  and  it  is  well  to  be  guarded  in  every  acute  case  when 
expressing  an  opinion;  for  an  apparently  simple  case  may  suddenly 
show  dangerous  or  even  fatal  symptoms.  It  is  a  well-known  fact  that  in 
the  simple  catarrhal  cases  there  may  never  be  but  one  attack,  perfect 
recovery  resulting. 

Many  cases  of  exudation  or  abscess,  especially  of  the  old  cases  of 
so-called  perityphlitis,  have  recovered  without  operation. 

Sahli  has  collected  7213  cases;  of  these,  473  were  operated  on,  6740 
were  not. 

Of  the  latter,  591  (8.8.  per  cent.)  died;  6194  (91.2  per  cent.)  recovered; 
recurrences  took  place  in  4593  cases;  of  these  3653  recovered  without  a 
second  recurrence. 

Nothnagel  claims  that  80  per  cent,  of  cases  of  circumscribed  appen- 
dicitis recover  under  medical  treatment. 

The  fact  that  a  patient  has  recovered  under  medical  treatment  from 
one  or  two  attacks  during  a  period  of  several  years  is  no  guarantee  that 
a  fatal  issue  may  not  ultimately  occur.  If  a  simple  catarrhal  attack  oc- 
curs, with  moderate  symptoms  and  no  marked  changes  in  the  blood 
the  prognosis  for  immediate  recovery  is  certainly  favorable.  If  no 
attacks  occur  during  several  years,  the  chances  of  subsequent  attacks 
are  lessened.  In  all  statistics  of  a  second  attack  and  subsequent  apparent 
cure,  the  history  should  be  investigated  for  some  years.     In  many  cases, 

*  Amer.  Jour.  Med.  Sci.,  Nov.,  1908. 


APPENDICITIS  835 

when  recurrence  has  taken  place,  we  find  chronic  appendicitis  and  prac- 
tically invalidism  as  a  result. 

If  in  acute  cases  there  are  marked  blood  changes  with  high  poly- 
nuclear  count  the  danger  is  imminent. 

Treatment. — The  medical  treatment  of  acute  appendicitis  can  be  sum- 
med up  very  briefly.  Absolute  rest  in  bed  in  the  dorsal  position.  The 
bowel  and  urine  evacuation  should  occur  with  the  patient  confined  to  bed. 

The  physician,  having  made  his  diagnosis  of  acute  appendicitis, 
to  the  exclusion,  of  course,  of  general  peritonitis,  should  pursue  the 
following  course:  All  food  and  even  water  at  first  should  be  prohibited 
by  mouth.  Sonnenburg  recommends  the  castor-oil  treatment  of  ap- 
pendicitis, but  the  writer  believes  it  dangerous.  No  cathartic  should 
at  this  time  be  given.  Thirst  can  be  relieved  by  rinsing  the  mouth  with 
cold  water,  by  small  rectal  injections  of  2  to  3  ounces  (60.0-90.0)  of  hot 
normal  salt  solution  at  105°  to  io8°F.,  or  by  proctoclysis.  If  there  is 
much  distention,  or  if  nausea  or  vomiting,  lavage  should  be  carefully 
performed.  In  these  methods  I  agree  with  Ochsner.  In  the  following 
I  differ.  If  the  lavage  does  not  markedly  relieve  the  distention  (if  such  be 
present),  I  would  then  advise  the  physician  to  personally  gently  wash  the 
bowel  with  tube  and  funnel,  after  the  method  of  lavage.  Only  about 
a  quart  of  normal  saline  in  all,  at  iio°F.,  need  be  employed,  allowing  a 
few  ounces  to  flow  in  and  then  siphoning  it  out.  This  practically  me- 
chanically carries  off  the  gas  and  has  little  influence  in  producing  active 
peristaltic  action.  A  similar  technic  is  employed  in  acute  distention  of 
typhoid  fever  with  active  hemorrhage.  He  should  carefully  note  the 
patient's  temperature,  the  rapidity  and  character  of  the  pulse,  and  the 
ratio  of  pulse  to  temperature.  When  feasible,  I  advocate  blood  ex- 
amination in  every  case,  though,  of  course,  it  is  in  some  cases  impossible.^ 
The  physician  should  return  to  his  case  in  two  or  three  hours  for  the  purpose 
of  further  examination.  The  ice-bag  should  be  applied  to  the  painful 
area  at  the  first  visit. 

The  pain  in  almost  every  case  can  be  controlled  by  the  use  of  an 
ice-bag  of  light  weight  and  a  small  amount  of  ice  therein,  so  arranged, 
supported  by  a  circle  of  gauze,  that  only  the  sensitive  area  is  touched 
by  it.  A  thin  layer  or  two  of  gauze  can  be  placed  between  the  bag 
and  the  skin,  so  no  damage  can  be  done  by  the  cold,  which  should  be 
continuously  applied.  The  bag  can  also  be  suspended  from  a  barrel 
hoop  to  take  off  the  weight,  but  the  former  method  is  the  simplest. 

In  emergency  I  have  used  bits  of  ice  tied  up  in  dress  shields  or  in 
pieces  of  rubber  tissue  as  a  substitute  for  the  bag. 

On  the  third  visit  or  the  one  thereafter  (all  of  which  visits  should 
be  made  within  a  total  period  of  six  to  eight  hours)  some  definite 
determination  as  to  the  proper  course  to  follow  at  that  specific  time  can 
be  made.  Lavage  may  again  be  indicated  to  relieve  distention,  or 
even  the  special  intestinal  washing,  as  previously  described.  Fre- 
quently, however,  under  abstention  from  food  and  drink  and  the  applica- 
tion of  ice  the  tympanites  will  be  markedly  relieved  and  physical  examina- 
tion be  comparatively  easy.  If  there  is  a  history  of  long  constipation,  and 
'  This  last  refers  to  country  practice . 


836  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

on  examination  a  fecal  accumulation  can  he  determined  in  the  cecum,  I 
resort  to  radical  treatment. 

Fecal  accumulation  with  gaseous  distention  is  an  actual  danger 
by  causing  pressure  on  the  inflamed  appendix.  I  always  resort  in  such 
cases  to  enema  or,  preferably,  gentle  intestinal  irrigation  once  or  twice  a 
day  every  day  with  normal  saline  solution,  with  two  tubes  or  a  recurrent 
tube,  using  2  to  3  or  4  quarts  at  each  lavage,  only  y^  pint  at  a  time,  at 
110°  to  ii5°F.,  emptying  the  large  intestine  mechanically.  I  have  fre- 
quently seen  the  acute  symptoms  rapidly  subside  with  the  above  method. 
These  cases  are  not  so  very  rare. 

At  the  end  of  forty-eight  hours,  with  symptoms  defervescing,  a 
dose  of  calomel,  castor  oil,  or  a  saline  cathartic  is  then  indicated.  K 
there  is  vomiting,  oxalate  of  cerium  or  bismuth  and  heat  to  epigastrium; 
for  excessive  vomiting,  lavage. 

The  type  with  fecal  impaction  is  the  only  class  of  cases  in  which 
such  radical  methods  are  resorted  to.  If  in  other  acute  cases  in  the 
course  of  the  first  eight  hours  the  temperature  does  not  rise  markedly, 
and  especially  if  the  pulse  does  not  increase  in  frequency,  but  rather 
diminishes,  and  its  character  improves,  with  improvement  in  the  other 
symptoms,  delay,  with  careful  watching  of  the  patient,  is  allowable.  The 
attack  then  may  gradually  entirely  subside  with  no  subsequent  recurrence, 
or  a  fresh  attack  may  take  place  after  an  interval.  In  the  case  of  a  first 
a.ttack,  comparatively  mild,  I  would  not  advise  operation  directly  after 
the  attack  unless  the  patient  contemplated  a  journey  beyond  the  reach 
of  a  surgeon.  Interval  operation  is  always  preferable.  The  indications 
for  immediate  surgical  intervention  are  given  later. 

Diet. — As  to  diet,  I  am  not  quite  as  radical  as  Ochsner  in  all  cases. 
For  two  days  in  the  acute  attack,  no  matter  what  the  type,  I  allow 
nothing  by  mouth,  neither  food  nor  water.  This  checks  peristalsis,  as 
Ochsner  claims,  and  furthermore  places  the  patient  in  the  best  condition 
for  operation  should  such  suddenly  become  necessary.  The  mouth  is 
rinsed  and  hot  salines  are  given  by  enema  or  by  proctoclysis.  After  two 
days  I  allow  small  quantites  of  hot  water  by  mouth,  and  if  the  tem- 
perature is  ioo°F.  or  over,  no  food  by  mouth,  but  nutritive  enemata.  As 
soon  as  the  temperature  falls  to  ioo°F.  or  below,  food  is  given  by  mouth 
in  small  quantities  at  first.  The  general  diet  should  then  be  fluid  for 
some  days;  no  gaseous  fluid  should  be  given.  Milk  well  diluted  with  lime- 
water  or  equal  parts  with  barley-water,  oatmeal-water,  rice-water,  gruels, 
zoolak,  fermillac,  bacillac,  etc.,  are  excellent.  Personally,  I  believe  the 
gruels  preferable  to  milk,  as  causing  less  tympanites;  as  the  symptoms 
subside,  eggs  beaten  up  with  milk,  bouillon,  chicken  broth,  and,  later, 
soft-boiled  eggs  and  milk-toast  are  added. 

I  agree  with  Ochsner  that  lavage  is  valuable  for  the  distention  or 
for  vomiting.  If  the  tympanites,  however,  is  not  relieved  by  the  lavage, 
I  believe  the  funnel  method  of  gentle  irrigation  of  the  bowel  to  be  perfectly 
safe.  If  fecal  accumulation  occur  later  during  the  attack,  a  soapsuds 
enema  is  indicated.  A  cathartic  should  not  be  given  by  mouth  during 
the  early  acute  stage  until  the  temperature  falls  to  below  ioo°F.,  or 
particularly  until  the  local  symptoms  defervesce.     Fecal  impaction  is 


APPENDICITIS  837 

the  exception.  Catarrhal  colitis  should  receive  treatment  as  soon  as  the 
acute  stage  of  appendicitis  has  subsided. 

Opium  has  long  been  a  much-vaunted  remedy,  on  the  theory  of 
quieting  peristalsis  and  allowing  adhesions  to  form;  also  for  relieving 
pain;  and  given  preferably  as  laudanum,  or  by  suppository.  /  am 
absolutely  opposed  to  its  use.  The  character  of  the  pulse  and  respiration 
are  changed  thereby;  muscular  rigidity  will  relax,  and  I  have  seen  the 
symptoms  of  perforation,  both  of  the  appendix  and  gall-bladder,  entirely 
masked  by  its  employment.  Tympanites,  distention,  and  intestinal 
paresis  are  more  apt  to  occur  as  a  result  of  its  use.  The  application  of 
heat  I  am  opposed  to  in  acute  cases.  It  is  difficult  to  secure  a  continuous 
high  degree  of  heat  and  a  warm  poultice  is  deleterious. 

The  ice-bag  continuously  applied  possesses  all  advantages  and  no 
disadvantages;  and  I  only  advise  the  use  of  a  single  small  dose  of  morphin 
by  hypodermic,  and  find  it  but  seldom  necessary,  if  the  ice  does  not 
control  the  pain. 

Frequent  examinations  of  the  blood  as  regards  differential  leuko- 
cytosis and  hyperinosis  should  be  made  in  every  case  when  possible, 
at  first  at  least  twice  daily,  and  thereafter  once  a  day. 

If  the  differential  count  is  not  marked  and  does  not  increase,  but  rather 
diminishes,  and  the  symptoms  gradually  defervesce,  do  not  operate  during 
the  acute  attack. 

The  indications  for  operation  are  as  follows:  i.  If  the  patient  shows 
the  symptoms  of  acute  peritonitis  when  first  seen  or  suddenly  develops 
them — general  muscular  rigidity,  tender  abdomen,  tympanites,  etc. — 
operate  immediately. 

2.  If  there  be  found  on  examination  an  area  of  resistance  in  the 
right  iliac  fossa,  and  this  increases  with  more  marked  symptoms  after 
six  to  eight  hours'  observation,  whether  chills  be  present  or  not,  opera- 
tion is  indicated. 

An  aspirating  needle  should  never  he  employed  for  purposes  of  diagnosis. 
The  blood-count  is  of  value  as  an  aid  to  prognosis  and  diagnosis,  if 
the  physician  has  the  technical  skill  or  can  have  it  done. 

3.  In  a  large  abscess,  in  complicated  cases,  or  when  temperature  is 
steadily  rising,  operate. 

4.  If  the  course  of  the  disease  is  protracted  and  the  symptoms  point 
to  abscess  or  an  active  and  progressive  process,  operate. 

5.  In  acute  fulminating  cases.  In  this  type,  with  apparently  mild 
local  symptoms,  but  especially  a  gradual  increase  of  pulse  and  a  moderate 
increase  of  temperature,  there  should  he  immediate  operation.  The  blood 
examination  is  important,  if  possible. 

6.  A  frequent  pulse  increasing  in  rapidity,  not  corresponding  to  the  more 
gradual  rise  of  temperature,  indicates  immediate  operation.  In  all  cases 
when  the  differential  blood-count  is  marked  and  increasing,  operate  at 
once. 

7.  If  the  patient  have  a  mild  attack  and  subsequently  develop  a  second 
attack  (of  less  severe  t>^e  than  the  first),  delay  may  occur;  but  if  a  third 
attack  occur,  then  an  interval  operation.  If  the  second  attack  be  more 
severe  than  the  first,  then  operate  at  once. 


838  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

8.  In  chronic  appendicitis,  with  symptoms  persistent  and  invalidism 
occurring  as  a  result,  or  if  recurrent  acute  exacerbations,  operate. 

9.  In  harmful  involution  of  the  appendix,  operate. 

In  effect,  the  best  judgment  is,  operate  within  twelve  to  sixteen  hours 
from  the  onset  if  improvement  does  not  occur. 

The  surgeon  should  operate  during  the  intermediate  stage  with  a 
spreading  inflammatory  process,  if  he  unfortunately  sees  the  patient  for 
the  first  time  during  this  period.  A  rapid  operation  with  little  manipu- 
lation is  best  at  this  time.  In  this  I  disagree  with  Ochsner,  who  does  not 
operate  at  this  stage.     I  continue  the  other  part  of  his  treatment,  however. 

It  is  furthermore  interesting  to  note  that  in  C.  McWilliams'  analysis 
of  141 1  operations  upon  the  appendix  at  the  Presbyterian  Hospital,  New 
York,  one  case  died  following  operation  for  acute  appendicitis  during  the 
first  sixteen  hours,  and  that  of  pericarditis.  MortaUty  during  first 
twenty-four  hours  was  5  per  cent.  Operations  on  third  to  sixth  day, 
mortality  was  12.7  per  cent.;  from  the  seventh  to  the  tenth  day,  mortality 
was  20.2  per  cent.,  and  thereafter,  13.4  per  cent. 

The  method  of  operation  depends  on  the  location  and  type  of 
appendicitis. 


CHAPTER  XXXII 

DIVERTICULITIS— PERIDIVERTICULITIS— DISEASES  OF 
MECKEL'S  DIVERTICULUM 

{Synonyms. — Sigmoiditis ;  Perisigmoiditis) 

History. — During  the  past  fifty  years  specimens  of  false  diverticula 
of  the  descending  colon  and  sigmoid,  both  with  and  without  concretions, 
have  been  reported  by  pathologists,  who  have  demonstrated  their  rela- 
tionship to  general  or  local  peritonitis.  Only  recently  has  attention  been 
especially  focused  on  inflammation  in  the  left  iliac  fossa,  and  the  terms 
"sigmoiditis"  and  "perisigmoiditis"  been  employed. 


Fig.  331. — Diverticulitis.  Sigmoid  laid  open  longitudinally.  A  diverticulum 
containing  a  sloughing  ulcer  is  seen  at  the  lower  right  hand;  another  is  sectioned  near 
the  label  needle  (W.  J.  Mayo). 

There  is  confusion  as  to  the  definition  of  sigmoiditis,  many  using  it  in 
the  sense  of  a  catarrh  of  the  sigmoid;  while  others  define  it  as  an  inflam- 
matory condition,  involving  to  a  greater  or  less  degree  this  entire  portion 
of  the  gut  (the  musculature  included).  In  other  words,  it  is  not  a  catarrh 
of  the  mucous  membrane.  It  was  so  defined  as  a  diffuse  inflammation 
by  PateP  and  will  be  so  employed  in  this  volume.  Specific  inflammations, 
such  as  dysentery,  tuberculosis,  and  syphilis,  are  excluded.  Eisendrath 
has  recently  contributed  to  this  subject. 

Diverticulitis-  and  peridiverticulitis,  as  when  productive  of  disturbance 


1  Revue  de  Chirurgie,  Oct.  and  Dec,  1907;  Lyon  Med.,  Oct. 
*  Sigmoid  Diverticulitis,  Archiv.  Diag.,  Oct.,  1909. 

839 


1905. 


840 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


they  occur  chiefly  in  the  sigmoid,  have  been  used  interchangeably  with 
sigmoiditis;  and  perisigmoiditis  bears  the  same  relationship  as  does 
perityphlitis  to  typhlitis. 


Fig.  332. — Diverticulitis.     Section  through  ulcerated  diverticulum  shown  in  Fig.  331 

(W.  J.  Mayo). 

Mayo  first  employed  the  term  sigmoiditis,  but  the  condition  was  first 
described  by  Joseph  M.  Mathews.     The  late  J.  P.  Tuttle'  has  contributed 


Fig.  ^$3. — Diverticulitis.  Enlarged  view  of  sectioned  diverticulum  shown  in 
Fig-  33^-  Note  muscularis  in  wall,  occluded  lumen,  and  inflamed  submucosa 
(W.  J.  Mayo). 

an  excellent  monograph  and  John  F.  Erdmann-  reports  16  cases  of  great 
interest.     Though  inflamed  diverticula  of  the  sigmoid  undoubtedly  cause 

^  Amer.  Jour.  Surg.,  April,  1909. 

*N.  Y.  Med.  Jour.,  Mar.  14,  1914,  and  Yale  Med.  Jour.,  February,  191 2. 


DIVERTICULITIS' — PERIDIVERTICULITIS 


841 


the  maximum  of  all  cases  of  sigmoiditis  and  perisigmoiditis,  having  about 
the  same  relation  to  left  iliac  abdominal  suppuration  as  the  appendix  has 
to  similar  conditions  in  the  right  iliac  fossa,  yet  other  causes  of  perisig- 


^19 

Bvn^*    jm 

II 

1*1 

^^^^^^^^^b  ^' 

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F^'»-ws  ■ 

fu3 

v/ 

K 

Sfi 

H 

\ 

jA 

■  '^- .  ■ 'S 

^^ 

L 

^ 

Jig-  334- — Peridiverticulitis.  Sigmoid  divided  longitudinally.  Note  defective 
musculature  and  the  diverticula.  Inflammatory  mass  dissected  away  near  label 
needle  (W.  J.  Mayo). 

moiditis  are  given,  such  as  ulcerations  extending  through  the  wall  of  the 
gut;  traumatism  or  puncture  by  foreign  bodies;  diverticula,  in  association 


Fig-   335. — ■Peridiverticulitis.     Enlarged    view   of   two   Ui.^iu^-ia   and   one   point   of 
defective   musculature   seen   in    Fig.    334    (W.    J.    Mayo). 

with  which  Byron  Robinson  and  Tuttle'  believe  that  traumatism  from  the 
iliac  and  psoas  muscles  play  a  part;  lumbricoid  worms  and  wisps  of  hay 

'  .\mer.  Jour.  Surg.,  April,  1909. 


842  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

entering  the  appendices  epiploicae.  Secondary  perisigmoiditis  is  also 
believed  to  occur  from  inflammation  by  extension  from  other  abdominal 
or  pelvic  organs. 

Wm.  J.  Mayo^  draws  a  sharp  distinction  between  diverticulitis  and 
peridiverticulitis  (Figs.  331-336). 

With  diverticulitis  there  is  a  primary  lesion  in  the  mucosa,  often  of 
an  ulcerative  type,  and  a  tendency  to  perforation  into  the  peritoneal 
cavity,  with  resulting  acute  peritonitis.  It  has  no  tendency  to  produce 
reduction  of  the  lumen  of  the  bowel. 

With  peridiverticulitis  there  is  a  leakage  of  toxins  and  bacteria  into 
the  subseyosa  and  tissues  surrounding  the  diverticulum,  with  resulting 
inflammation  and  thickening  of  the  gut,  so  that  its  lumen  may  be  markedly 
reduced  and  symptoms  of  obstruction  occur.  Perforative  peritonitis 
rarely  occurs  in  this  type,  as  so  much  reparative  inflammation  goes  on. 
Local  intraperitoneal  abscess  or  acute  or  chronic  obstruction  may  result. 


nLAascaaisrr^acnx:,;  '^^iH&i^^^^L^kj^ 


T.B'd^ 


Fig.  336. — Peridiverticulitis.     Sketch    of    diverticulum    with    inflammatory    deposit 
in  subserosa  (W.  J.  Mayo,  Wilson,  and  GifiBn). 

Lejars,^  Bittorf,^  and  Rosenheim^  classify  sigmoiditis  and  perisig- 
moiditis clinically.  Gordinier  and  Sampson^  hold  that  these  conditions 
are  more  frequent  than  we  suppose. 

Diverticula  of  the  Intestines. — Diverticula  are  formed  by  a  bulging 
or  protrusion  of  the  intestinal  wall,  and  are  divided  into  the  congenital  and 
the  acquired. 

In  the  congenital  forms  the  wall  of  the  diverticulum  is  formed  by  the 
whole  intestinal  wall;  and  these  have  been  called  "true"  diverticula. 
It  was  formerly  thought  that  all  acquired  diverticula  were  of  the  "false" 
type,  consisting  of  protrusions  of  the  mucosa  through  spaces  in  the 
muscular  coat,  so  that  their  wall  comprised  mucosa  and  serosa.  It  has 
been  demonstrated  that  acquired  diverticula  may  be  of  the  "true"  type, 

1  Surgery,  Gynecology,  and  Obstetrics,  July,  1907. 

*  Semaine  Medicale,  June  27,  1904,  p.  26. 
'  Miinch.  med.  Wochenschr.,  1904,  p.  147. 

*  Zeits.  fiir  Klin.  Med.,  1904,  Band,  liv,  p.  475. 

*  Jour.  Amer.  Med.  Assoc,  1.906,  vol.  i,  p.  1686. 


DIVERTICULITIS — PERIDIVERTICULITIS 


843 


and  are  causjed  most  frequently  by  traction  from  tumors  or  adherent 
organs.  False  diverticula  are  the  result  of  excessive  pressure  within  the 
intestines  combined  with  a  congential  weakness  of  the  bowels.  The  chief 
congential  diverticulm  of  importance  is  Meckel's. 

Meckel's  diverticulm^  due  to  the  persistence  or  incomplete  obliteration 
of  the  omphalomesenteric  duct,  usually  rises  from  the  ileum  yi  to  i  meter 
above  the  ileocecal  valve,  from  the  convex  margin  of  the  intestines  opposite 
the  mesenteric  attachment,  and  varies  in  length  from  3  to  10  cm.,  though 
rarely  longer. 

Congenital  diverticula  have  been  found  in  the  small  and  large  intes- 
tines. An  accessory  pancreas  may  be  responsible  for  a  diverticulm  in 
the  stomach  or  small  intestines. 


Fig.  337. — Hodenpyl's  specimen  of  multiple  acquired  diverticula  of  the  colon  (sigmoid 

flexure)   (Brewer). 

Acquired  diverticula  occur  both  in  the  small  and  large  intestines, 
and  have  even  been  recorded  in  the  appendix  by  EdeP  and  Mertius.* 
They  are  generally  more  frequent  in  the  large  intestine,  especially  in  the 
lower  part  of  the  descending  colon  and  sigmoid  flexure,  the  latter  pro- 
viding the  most  examples,  as  in  Fig.  337,  reported  by  G.  Brewer.^  Here 
they  are  usually  multiple. 

Autopsies  in  death  from  other  causes  have  been  reported  where  diver- 
ticula were  found,  but  no  symptoms  had  ever  occurred.  As  many  as 
400  diverticula  in  one  case  have  been  noted  by  Hausemann. 

^  Virchow's  Archiv,  Bd.  cxxxviii. 

^Mitheilung  ans  der  Grenzgebiet  fur  Med.  und  Chir.,  Bd.  ix. 

*Amer.  Jour.  Med.  Sci.,  Oct.,  1907. 


844 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


One  case  of  diverticulitis  of  the  small  intestine  which  gave  symptoms 
has  been  recorded  by  Gordinier  and  Sampson.^ 

With  diverticula  of  the  appendix,  appendicitis  has  been  simulated, 
but  it  is  clinically  unimportant  to  separate  the  conditions,  as  operation  is 
indicated  in  any  event.     Diverticula  are  most  frequent  in  the  sigmoid 


1999 


Fig.  338. — Diverticula  of  sigmoid  showing  enteroliths  in  situ.  The  abundant 
fat  has  been  dissected  from  off  one-half  of  the  bowel,  showing  the  pouches  which 
entered  the  appendices  epiploicae.  At  a  a  single  pouch  has  been  dissected  out  and 
shows  well  how  they  are  buried  in  fat  and  liable  to  pass  unrecognized  unless  specially 
sought  for;  b,  longitudinal  muscular  band;  c,  a  concretion  (W.  H.  Maxwell  Telling). 

flexure.  Quite  a  number  give  important  symptoms.  E.  Beer^  has  de- 
scribed the  clinical  symptoms  of  diverticulitis,  and  Telling^  has  collected 
105  cases,  giving  a  thorough  exposition  of  the  subject  (Figs.  338-342). 

Suduski^  found  diverticula  present  15  times  in  40  autopsies,  so  that  the 
condition  is  probably  more  frequent  than  has  been  supposed,  and  has 
often  been  overlooked,  even  in  postmortem. 

1  Jour.  Amer.  Med.  Assoc,  1906,  vol.  i,  p.  1684. 
*Amer.  Jour.  Med.  Sci.,  July,  1904. 

*  Lancet,  March  21  and  28,  1908. 

*  Langenbeck's  Archiv.,  Bd.  Ixi,  p.  708. 


DIVERTICULITIS — PERIDIVERTICULITIS 


845 


Brewer^  has  reported  a  case  of  acute  diverticulitis  of  the  sigmoid,  with 
operation  before  rupture. 

Occurrence. — Acquired  diverticula  are  much  more  common  in  the 
large  intestine,  more  so  in  the  descending  colon,  and  especially  so  in  the 
sigmoid  flexure.  They  are  usually  multiple  and  may  arise  from  any  part 
of  the  surface.  They  are  frequently  seen  in  two  rows  at  the  sides  of  the 
gut,  or  close  to  the  mesenteric  attachment,  more  rarely  on  the  convexity. 
Charles  Mayo^  reports  two  cases  of  diverticula  of  the  rectum  and  one 
in  the  anal  ring. 


1909 


A  B 

Fig.  339. — Diverticula  of  sigmoid.  A,  The  fat  has  been  dissected  from  off  the 
outer  aspect  of  the  bowel.  The  pouches  are  for  the  most  part  into  the  appendices 
epiploicae.  One  of  the  sacs  is  laid  open  at  a.  B,  Inner  surface  of  the  bowel  from 
the  same  specimen.  A  concretion  is  seen  at  b  presenting  at  the  orifice  of  one  of  the 
diverticula.     At  c,  the  lipped  orifice  is  well  seen  (W.  H.  Maxwell  Telling). 

Chlumsky  claims  that  he  finds  by  experiment  that  rupture  in  the 
living  bowel  upon  distention  occurs  more  frequently  opposite  the  mes- 
entery. The  general  opinion  is  that  the  mesenteric  side  is  less  resistant. 
Probably  the  most  common  occurrence  of  these  diverticula  is  in  the 
appendices  epiploicae.  In  many  cases  they  are  confined  to  them,  and  pre- 
sent a  double  row  of  symmetrically  placed  hoUowed-out  pockets.  In 
other  cases  none  are  so  situated,  and  frequently  some  enter  the  appendices 
and  some  lie  outside  of  them.     The  presence  of  the  diverticula  in  these 

'Jour.  Amer.  Med.  Assoc,  Aug.  15,  1908. 
*  Jour.  A.  M.  A.,  July  27,  191 2. 


846 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


appendices  may  account  for  some  of  the  tenderness  found  in  many  por- 
tions of  the  gut.  The  special  favoring  of  the  epiploicae  is  accounted  for 
by  the  fact  that  the  point  of  their  attachment  to  the  gut  is  a  place  of  least 
resistance. 

In  a  majority  of  cases  the  affected  appendages  have  been  or  are  filled 
with  a  large  amount  of  fat. 

Bland-Sutton^  has   stated   and   illustrated   by   diagrams   that    this 
fat  is  directly  continuous  with  the  subserous  fat.     If  there  is  the  slightest 

tendency  to  the  formation  of  diver- 
ticula, it  will  readily  be  seen  that 
the  soft  fatty  tissue  of  the  appen- 
dices epiploicae  form  a  point  of 
lowered  resistance. 

Size. — The  diverticula  vary  in 
size  from  a  millet-seed  to  a  hazel- 
nut. Large  size  is  seldom  attained, 
as  secondary  changes  occur  leading 
to  detachment,  ulceration,  abscess, 
or  peritonitis. 

When  small,  they  are  semiglob- 
ular;  as  they  increase  in  size,  more 
oval  or  flask  shaped;  the  aperture  on 
the  gut  wall  usually  being  smaller 
than  the  maximum  diameter  of  the 
diverticulum,  and  almost  constantly 
so  when  they  enter  the  appendices 
epiploicae. 

This  is  an  anatomic  point  of  great 
importance  in  regard  to  the  causation 
of  inflammation.  In  those  which  do 
not  enter  the  appendices  the  aperture 
may  be  relatively  large.  They  are 
then  generally  true  diverticula  and 
are  formed  from  normal  haustra 
(Sudsuki),^  usually  not  extending 
much  above  the  middle  of  the  de- 
scending colon.  They  increase  in 
nimiber  and  size  from  above  down- 
ward, and  may  be  quite  crowded  to- 
gether in   the  sigmoid  flexure.     At 


Fig.  340. — Diverticula  of  sigmoid. 
The  fat  has  been  partly  dissected  from 
off  the  outer  surface  of  the  gut,  showing 
several  pouches.  At  a  is  seen  a  larger 
one  containing  a  calcareous  concretion, 
with  a  thin  fibrous  pedicle  in  the  proc- 
ess of  separation  to  form  a  loose  peri- 
toneal body.  A  similar  concretion,  the 
size  of  a  bean,  was  free  in  the  pelvis 
(W.  H.  Maxwell  Telling). 


the  commencement  of  the  rectum 
they  generally  stop  abruptly.  This  is  possibly  due  to  the  absence  of 
appendices  epiploicae  in  this  situation;  but  the  fact  that  the  feces  are  not 
retained  so  long  in  this  part  of  the  bowel  is  also  partly  responsible. 
Schreiber^  thinks  that  the  stronger  musculature  of  the  rectum  plays 
some  part  in  preventing  their  formation.  Mayo,  as  noted,  reports  3  cases 
in  this  region. 

^Lancet,  Oct.  24,  1903,  p.  1148. 

*  Langenbeck's  Archiv,  Band  Ixi,  p.  708. 

'  Deutsch.  Archiv  fur  Klin.  Med.,  1902,  p.  122. 


DIVERTICULITIS — PERIDIVERTICULITIS  847 

They  are  almost  invariably  filled  with  fecal  material,  generally  con- 
cretions of  some  degree  of  firmness.  This  fact  probably  determines  their 
subsequent  clinical  importance,  and  sharply  distinguishes  them  from 
acquired  diverticula  in  the  small  intestine,  which  rarely  contain  fecal  material. 
To  this  we  can  ascribe  the  immunity  of  the  latter  from  secondary  patho- 
logic processes  and  symptoms. 

Usually  in  the  early  stages  all  the  coats  of  the  bowel  are  represented, 
but  in  some  the  muscularis  is  absent.  There  has  been  controversy 
as  to  the  presence  or  absence  of  muscular  fibers  in  the  diverticulum  wall. 
Cruveilhier  and  Rokitansky  originally  regarded  the  diverticula  as  hernial 
protrusions  of  the  mucous  and  serous  coats,  with  absence  of  muscular 
tissue.  The  presence  or  absence  of  muscle  was  for  many  years  the 
criterion  for  distinction  between  congenital  and  acquired  diverticula. 

The  microscopic  findings  in  numerous  cases  show  that  acquired 
diverticula  often  have  all  the  coats  of  the  bowels  represented.  In  the  early 
stages  of  the  formation  it  is  almost  the  rule,  although  the  muscular  tissue 
undergoes  atrophy  as  the  sac  enlarges. 

Etiology. — One  case  of  an  acute  catarrhal  inflammation  of  a  diver- 
ticulum of  the  sigmoid  has  been  recorded  in  a  child^  seven  years  of  age, 
while  the  great  majority  are  in  old  or  even  aged  subjects.  More  recently, 
J.  A.  Hartwell-  and  R.  L.  Cecil  have  reported  a  careful  study  of  18  cases 
of  intestinal  diverticula.  They  find  that  children  and  young  adults  are 
also  subject  to  them  and  to  the  secondary  changes  occurring  in  them. 
They  seem  to  be  generally  acquired. 

1.  Generally,  advanced  age  of  the  patient.  In  80  cases  the  average 
age  was  sixty  years,  but  of  those  in  whom  diverticula  caused  symptoms 
in  47  cases,  the  age  was  fifty-five  years.  In  t,t,  cases  no  symptoms  were 
referred  to  their  presence,  but  they  were  accidentally  discovered,  the  age 
was  sixty-seven.  Fiedler^  records  the  youngest  case  at  twenty-two 
years.     William  J.  Mayo  places  the  majority  at  over  fifty  years. 

2.  Sex. — In  81  cases — 53  males,  28  females. 

3.  Obesity. — Klebs,  Mayo,  and  others  have  laid  stress  on  this.  Many 
have  been  fat;  the  presence  of  much  fatty  tissue  in  the  gut  walls  and 
appendices  epiploicae  have  been  sho\Mi  by  Bland-Sutton  to  predispose  to 
mucosal  out-pushings.  In  22  cases,  17  were  stated  to  be  more  or  less 
obese  and  to  have  much  fatty  tissue  in  the  gut  wall. 

4.  Cachexia  and  Absence  of  Fat. ^-On  the  other  hand,  many  sub- 
jects are  noted  as  having  been  thin  (Hausemann)^;  5  of  the  22  cases 
were  stated  to  be  of  this  type.  Undoubtedly  some  had  previously 
been  obese,  and  from  age  or  illness  had  lost  much  of  their  fatty  tissue. 
This  has  not  been  definitely  referred  to.  It  will  be  readily  understood 
that  the  fatty  deposit  would  first  weaken  the  gut  wall;  the  subsequent 
loss  of  fat  with  possible  concomitant  weakening  and  wasting  of  the 
muscle-fibers  would  probably  increase  this  tendency. 

5.  The  Normal  Structure  of  the  Large  Intestine. — This  readily  lends 
itself  to  local  yielding  of  its  walls,  as  is  suggested  by  the  normal  sacculi, 

*  Ann.  of  Surg.,  vol.  xlvii,  by  A.  P.  C.  Ashhurst. 

*  Amer.  Jour.  Med.  Sci.,  Aug.,  1910. 

^  Denkschriit  der  Gesellschaft  fiir  Natur.  v.  Heilknade,  Dresden,  1868. 

*  Virchow's  Archiv,  Band  cxliv. 


848  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

which  are  often  exaggerated  in  cases  of  constipation,  sometimes  in  association 
with  diverticula. 

6.  Physiologic  Rdle  of  the  Sigmoid  Flexure. — In  this  portion  of  the 
bowel  is  the  longest  retention  of  fecal  material,  and  here  consequently 
the  pressure  from  within  will  he  liable  to  be  the  greatest. 

7.  Pressure  from  Within  the  Bowel. — This  may  be  due  to  accumu- 
lation of  feces  or  gas,  or  both. 

(a)  Presence  of  Constipation. — ^This  stands  in  most  frequent  and  im- 
portant causal  relationship  to  this  condition.  In  22  cases  in  which  the 
point  is  definitely  mentioned,  constipation,  often  severe  and  generally 
for  a  considerable  period,  was  present  in  17.  In  the  remaining  5  its 
absence  was  particularly  noted.  Constipation  in  old  people,  whether 
obese  or  emaciated,  is  very  common,  while  diverticula  are  comparatively 
rare;  hence,  other  factors  must  be  present. 

(b)  Flatulence. — This  is  usually  associated  with  constipation,  and 
acts  in  the  same  way  by  increasing  internal  pressure;  so  much  stress 
has  been  laid  on  the  factor  of  internal  pressure  that  the  term  ^^  pulsion 
divertiulca"  has  been  applied  to  them. 

8.  The  Relation  of  the  Diverticula  to  the  Points  of  Entry  of  the  Vessels 
through  the  Gut  Walls. — This  fact  was  first  pointed  out  by  Klebs^  in  the 
case  of  acquired  diverticula  in  the  small  intestine,  and  has  been  confirmed 
by  others  (Hausemann  and  Fisher)  with  regard  to  the  large  intestine. 

Microscopically  it  is  evident  that  the  spots  in  the  gut  wall  where  it 
is  pierced  by  the  vessels  are  areas  of  weakened  resistance  to  internal  pressure, 
because  the  vessels  are  accompanied  by  a  certain  amount  of  lax  con- 
nective tissue,  through  which  an  out-pushing  of  the  mucous  membrane 
can  more  easily  take  place. 

9.  Variations  in  the  Size  of  the  Vessels. — Graser^  was  the  first  to 
investigate  this  point.  In  his  case,  the  patient  sufifered  from  chronic 
heart  disease,  with  venous  back-pressure,  leading  to  distention  of  the 
veins  in  the  gut  wall.  This  dilatation  he  regarded  as  further  weakening 
the  vessel  spaces  by  pushing  aside  the  muscular  fibers.  He  examined 
microscopically  the  sigmoids  of  28  patients  who  had  suffered  prior  to 
death  from  mesenteric  venous  stagnation.  In  10  of  them  he  found  definite 
evidence  (mostly  microscopic)  of  commencing  out-pushings  of  the  gut-wall; 
and  in  every  case  they  occurred  through  these  ''vessel  holes." 

The  diverticula  were  most  numerous  in  the  sigmoid  and  practically 
ceased  at  the  middle  of  the  ascending  colon. 

Mesenteric  venous  congestion  may  be  due  to  chronic  heart  or  lung 
disease,  portal  back-pressure,  or  intra-abdominal  tumor,  etc. 

"He  is  inclined  to  ascribe  a  special  importance  to  a  distention  which 
is  not  constant,  but  of  frequent  repetition,  as  recurs  in  the  repeated 
failures  of  cardiac  compensation  and  in  frequent  recoveries  therefrom 
in  patients  with  chronic  heart  disease." 

When  the  vessels  are  engorged  the  vessel  holes  are  enlarged;  when 
they  are  smaller  these  areas  are  thereby  weakened,  and  there  is  a  greater 
liability  to  hernia  of  the  mucosa. 

'  Pathologic  Anatomy,  1869,  p.  271. 
2  Centralbl.  fur  Chirurg.,  1898,  etc. 


DIVERTICULITIS — PERIDIVERTICULITIS  849 

While  in  the  small  intestine  the  diverticula  are  practically  always 
on  the  mesenteric  side  of  the  bowel  where  the  vessels  pierce  the  walls, 
in  the  larger  bowel  many  of  the  diverticula  occur  on  the  side  remote  from 
the  mesentery.     Another  explanation  must  be  sought  for. 

Therefore,  Schrieber  believed  the  congestion  of  the  vessels  was  second- 
ary to  the  presence  of  feces  in  the  diverticulum,  rather  than  to  the  original 
cause  of  the  formation  of  the  latter. 

10.  The  Connective  Tissue  Around  the  Vessels. — Sudsuki^  found  in 
40  cases  not  suffering  from  mesenteric  venous  stagnation  which  he  ex- 
amined microscopically,  diverticula  present  in  15  bodies;  in  6  cases, 
true  diverticula,  that  is,  all  the  coats  were  therein.  In  20  cases,  where 
mesenteric  congestion  was  present,  he  found  diverticula  in  only  6;  in 
12  cases  free  from  congestion,  diverticula  were  found  in  9. 

The  subjects  were  all  adults  and  nearly  all  men,  middle  aged  or 
old.  He  suggests  there  is  a  congenital  predisposition  with  regard  to  the 
amount  and  laxity  of  connective  tissue  surrounding  the  vessels  at  these  spots; 
if  there  is  much  fatty  deposit,  this  will  act  in  the  same  way;  and  if  there 
be  subsequent  wasting  of  such  fatty  tissues,  further  weakening  takes  place. 

Beer  states  that  this  theory  fails  to  explain  the  non-mesenteric  diver- 
ticula and  those  which  have  muscular  layers  in  their  walls.  These  vessel 
spaces  have  some  influence,  but  they  have  some  additional  cause,  and 
Beer  finds  this  in  the  following: 

11.  Muscular  Deficiency  of  the  Gut  Wall. — Since  diverticula  occur 
in  old  people,  in  whom  the  muscular  power  of  their  intestines  has  been 
more  or  less  exhausted  (as  evidenced  by  constipation),  and  are  in  associa- 
tion with  obesity  (or  obesity  followed  by  cachexia),  these  facts  all  point 
to  a  muscular  deficiency. 

In  this  muscular  weakness  Beer  thinks  the  cause  of  the  false  diverticula 
must  be  sought. 

HartwelP  believes  that  an  inherent  weakness  existing  in  the  mus- 
cularis  of  the  intestines  is  probably  an  important  factor  in  the  etiology 
of  diverticula,  and  in  the  small  intestine  this  weakness  appears  to  exist 
along  the  mesenteric  attachment.  He  reports  a  number  of  cases  of 
diverticulitis,  and  Bruce^  describes  a  patient  with  perforation  of  a  diver- 
ticulum, abscess,  and  adhesions  with  a  secondary  appendicitis. 

In  Mayo's  cases  areas  of  muscular  deficiency  were  noted  opposite 
early  diverticula,  or  even  in  areas  yet  free  from  out-pushing.  Probably 
no  one  factor  is  sufficient. 

Out  of  105  cases  reported,  60  per  cent,  were  attended  with  symptoms 
(Telling). 

Secondary  Pathologic  Processes  in  the  Diverticula. — The  diver- 
ticula of  themselves  occasion  no  symptoms,  but,  as  one  would  expect, 
readily  undergo  inflammatory  changes  therein.  They  tend  in  most 
cases  to  form  fusiform  pouches  connecting  with  the  lumen  of  the  gut 
by  a  constricting  neck,  and  these  pouches  are  situated  for  the  most  part  on 
that  portion  of  the  bowel — the  sigmoid  flexure — of  which  the  normal 

'  Langenbeck's  Archiv,  Band  Ixi,  p.  708. 

2  Ann.  Surg.,  Aug.,  1910;  Amer.  Jour.  Med.  ScL,  Aug.,  1910,  p.  174. 

'  Ann.  Surg.,  May,  191 1. 

54 


850  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

anatomy  and  physiology  favor  most  the  retention  of  feces  and  the  accumu- 
lation of  gas.  If  a  condition  of  constipation  exists  and  the  "force  from 
within"  is  increased  it  is  almost  inevitable  that  they  will  from  the  first 
have  fecal  contents. 

On  account  of  the  narrow  neck  and  deficient  muscular  fibers  in  the 
sac  wall  the  contents  rarely  are  expelled  and  concretions  form.  These 
probably  cause  the  trouble.  The  first  result  would  be  a  tendency  to 
enlargement  of  the  sac.  Then  the  muscular  layers  atrophy,  as  do  the 
glands;  the  muscle  may  be  replaced  by  fibrous  tissue.  The  increase  in 
the  size  of  the  diverticulum  with  atrophic  changes,  in  its  walls,  produces 
necessarily  a  dangerous  thinning  of  the  sac.  In  some  cases  there  is  little 
more  than  a  peritoneal  covering,  with  the  contained  feces  visible  through  it. 
The  irritation  of  the  retained  and  hardened  feces  then  leads  to  inflam- 
matory changes.  These  may  be  slight  and  only  microscopic  in  the  mucosa 
and  submucosa,  or  may  produce  more  serious  acute  or  chronic  lesions. 
The  fecal  matter  is  a  nidus  for  bacteria;  their  products  undoubtedly 
determine  the  nature  of  the  inflammatory  reaction  which  occurs.  An 
ulceration  may  result  from  bacterial  infection.  Moreover,  the  con- 
cretion will  tend  to  be  forced  through  an  inflamed  or  ulcerated  area. 
These  features  explain  the  occurrence  of  local  abscess  or  general  peritonitis. 
The  latter  may  be  also  the  result  of  sudden  trauma  or  strain,  which  may 
cause  an  increased  pressure  within  the  bowel. 

Definite  types  are  produced  by  the  following  causes  (Telling)^: 

1.  Thinning  of  the  diverticulum  wall. 

2.  Perforating  action  of  the  retained  concretion. 

3.  The  presence  of  micro-organisms  and  their  toxins. 

4.  Inflammatory  reaction  of  varying  types  and  degree. 

With  these  data  one  can  forecast  the  various  cases  which  one  might 
expect  clinically;  viz.: 

1.  Infection  of  the  general  peritoneal  cavity  from  thinning  of  the 
sac  walls  without  perforation. 

2.  Acute  or  gangrenous  inflammation — "diverticulitis." 

3.  Chronic  proliferative  inflammation,  with  thickening  of  the  gut 
wall  and  stenosis  of  the  bowel — "peridiverticulitis." 

4.  Formation  of  adhesions,  especially  to  the  (a)  small  intestine, 
(6)  bladder. 

5.  Perforation  of  diverticula,  giving  rise  to  (a)  general  peritonitis, 
{b)  local  abscess,  (c)  submucous  fistulae  of  the  gut  wall,  {d)  fistulous 
communication  with  other  viscera,  especially  the  bladder. 

6.  The  lodgment  of  foreign  bodies.  7.  Chronic  mesenteritis  of 
the  sigmoid  loop.  8.  Local  chronic  peritonitis.  9.  Metastatic  sup- 
puration. 10.  Secondary  development  of  carcinoma.  11.  Perfora- 
tion into  a  hernial  sac.  12.  Formation  of  loose  bodies  in  the  peritoneal 
cavity. 

Eisendarth  gives  a  simple  clinical  classification: 

1.  Acute:  (a)  Acute  catarrhal;  {b)  acute  gangrenous,  with  or  without 
local  abscess;  (c)  acute  perforative,  with  general  peritonitis. 

2.  Chronic:  (a)    Chronic    hyperplastic    or    stenosing    (peridiverticu- 

1  The  Proctologist,  March,  191 1. 


DIVERTICULITIS — PERIDIVERTICULITIS 


851 


litis) ;  (b)  enterovesical  fistulous  form ;  (c)  chronic  adhesive  form,  causing 
acute  or  chronic  obstruction. 

The  following  classification,  by  Telling,  of  the  pathologic  processes 
which  result,  I  believe  the  most  scientific: 

1.  Infection  of  the  general  peritoneum  as  a  result  of  thinning  of  the 
sac  walls.  Organisms  make  their  way  through  the  wall  and  cause  peri- 
tonitis without  perforation.     Loomis^  records  one  case. 

2.  Acute  or  Gangrenous  Inflammation  of  the  Diverticulum  {Acute 
Diverticulitis). — Symptoms. — Pain,  tenderness,  and  swelling  in  the 
left  inguinal  region  are  present.  Local  abscess  or  general  peritonitis 
may  result.  Rigidity  of  the  left  rectus;  fever;  hyperinosis  (increased 
fibrin  in  the  blood);  leukocytosis;  increase  in  polynuclears  are  present. 
If  there  is  general  peritonitis,  we  have  the  additional  symptoms. 


Fig.  341. — Peridiverticulitis  with  great  thickening  of  the  gut  wall,  causing  stenosis 
and  simulating  carcinoma,  for  which  it  was  mistaken  when  resected  at  operation. 
The  thickening  due  to  fibrosis  is  seen  at  a  (W.  H.  Maxwell  Telling). 

3.  Chronic  Inflammation. — A  chronic  proliferative  inflammation  of  the 
submucous  and  serous  coats  may  occur.  Thickening  may  be  considerable. 
It  may  lead  to  {a)  tumor  formation,  ib)  stenosis  with  obstruction  (c) 
mimicry  of  carcinoma. 

This  last  type  of  inflammation  is  most  important,  most  frequent,  and 
generally  overlooked.  Crasser^  in  1898  first  described  a  case.  Moynihan 
recorded  one  as  also  did  Abbe.'  The  mimicry  of  carcinoma  is  so  perfect 
that  not  only  is  the  diagnosis  made  during  life,  but  also  at  the  operation, 
and  again  confirmed  erroneously  at  postmortem  (Fig.  341). 

Differential  diagnosis  between  carcinomatous  stenosis  and  diverticular 
stenosis  is  as  follows: 

With  carcinoma,  there  are  nearly  invariably  an  involvement  and  ulcera- 
tion of  the  mucous  membrane,  with  f  ungation  of  the  growth  into  the  lumen 

1  N.  Y.  Med.  Rec,  1870,  vol.  iv. 
-  Centralbl.  fur  Chirurg.,  1898. 
'  Med.  Rec,  Aug.  i,  19 14. 


852  DISEASES    OF   THE   STOMACH  AND   INTESTINES 

of  bowel.  With  diverticulitis  it  is  the  rule  for  the  mucous  membrane  to  be 
free  from  ulceration  (unless  a  fistulous  tract  or  abscess-cavity  open  into 
it  from  without  inward) ;  also  the  folds  of  the  mucosa  are  strongly  marked 
and  crowded  together,  giving  an  unduly  rugose  appearance  (Fig.  342), 
The  orifices  of  the  pouches  may  be  visible,  but  are  generally  small  and 
often  concealed  by  these  folds.  One  should  examine  the  folds  with  a 
fine  probe.  There  are  usually  absence  of  blood  and  pus  in  the  stool  in 
diverticulitis,  but  they  are  present  in  carcinoma. 

One  must  also  remember  that  carcinoma  of  the  sigmoid  may  originate 
from  diverticulitis. 

Age  of  the  patients  is  usually  the  same. 

Stenosis  may  cause  acute  or  chronic  obstruction  (Mayo). 


Fig.  342. — Sigmoid  showing  diverticula.  Inner  aspect  of  gut.  Normal  but 
rugose  mucosa.  The  orifices  show  well-marked  lipping  and  concretions  protruding 
partially  from  some  of  the  pouches  (W.  H.  Maxwell  Telling). 

4.  Formation  of  Adhesions. — (a)  Adhesions  to  the  small  intestine  may 
produce  acute  or  chronic  obstruction,  {b)  Adhesions  to  the  bladder  are 
also  noted. 

5.  Perforation  of  Diverticula. — Results  differ,  according  to  {a)  acute- 
ness  of  ulcerative  process,  {b)  amount  of  chronic  inflammatory  thickening 
present,  (c)  presence  of  adhesions. 

These  factors  determine  whether  perforation  leads  to  (a)  general 
peritonitis,  {b)  local  abscess  formation,  (c)  fistulous  communication  with 
other  viscera,  notably  the  bladder. 

{a)  General  perforative  peritonitis  has  occurred  in  14  cases.  C-  A. 
McWilliams  reported  a  case  at  the  Surgical  Society,  October  30,  1907, 


DIVERTICULITIS PERIDIVERTICULITIS  853 

upon  which  he  operated  at  the  Presbyterian  Hospital  for  general  peri- 
tonitis; the  history  of  constipation  was  of  only  a  week's  duration.  Male, 
aged  forty-seven.  The  case  was  believed  to  be  perforative  appendicitis, 
not  having  been  seen  until  general  peritonitis  was  in  evidence. 

Milky  fluid  under  considerable  tension  was  evacuated  at  operation. 
There  was  also  fluid  between  the  liver  and  diaphragm.  Appendix,  gall- 
bladder, stomach,  and  pancreas  were  examined,  but  no  perforation  was 
found. 

The  patient's  condition  became  such  that  further  search  was  deemed 
inadvisable.  Postmortem  showed  diverticula  of  large  size  commencing 
in  the  ascending  colon.  In  the  descending  colon,  10  cm.  below  the  splenic 
flexure,  a  perforation  of  a  diverticulum  was  discovered.  Culture  from 
the  peritoneum,  etc.,  showed  Bacillus  coli. 

(6)  Local  Abscess  Formation  in  24  Cases. — There  may  be  several  small 
abscesses  shut  ofif  by  thick  adhesions  or  a  single  large  abscess.  The  abscess 
may  be  intra-  or  extraperitoneal,  and  may  lead  in  turn  to  communication 
with  the  external  surface,  with  the  bladder  or  the  bowel. 

(c)  Submucous  Fistula. — In  some  cases  with  much  inflammatory 
thickening  the  ulceration  of  the  inside  of  the  sac  leads  to  a  small  abscess. 
This  happens  in  several  focci  in  the  thickened  area.  These  abscesses  tend 
to  burrow  through  the  thickened  tissues  and  form  submucous  fistulous 
communications  with  each  other.  There  may  be  a  labyrinth  of  such 
tracts.  They  may  re-enter  the  lumen  of  the  sigmoid  or  communicate 
with  a  peritoneal  abscess-cavity  by  one  or  several  openings.  This  sup- 
purating process  is  often  excessively  chronic  and  gives  rise  to  great 
thickening,  adhesions,  and  tumor  formation,  with  sequelae  in  the  shape  of 
intestinal  obstruction  or  adhesions  to  and  subsequent  perforation  of  the 
bladder. 

6.  Lodgment  of  Foreign  Bodies. — Diverticula  are  liable  to  harbor 
foreign  bodies,  which  may  give  rise  to  perforation,  diverticulitis,  or  local 
abscess.     Bland-Sutton  reports  several  cases. 

7.  Chronic  Mesenteritis. — In  some  there  is  inflammatory  thickening 
of  or  abscess  formation  in  the  sigmoid  mesentery.  It  is  believed  by  Ries^ 
that  retraction  of  the  sigmoid  loop  is  produced  thereby  and  also  adhesions, 
and  hence  twists,  kinks,  or  volvulus. 

8.  Local  Chronic  Peritonitis. — This  is  often  found  in  the  neighborhood 
of  the  sigmoid,  causing  thickening,  opacity,  or  adhesion  of  the  peritoneum, 
probably  in  some  cases  due  to  leakage  of  toxins  through  the  thin  wall  of 
an  overlooked  diverticulum,  though  at  times  due  to  the  pelvic  organs. 

9.  Metastatic  Suppuration. — One  case  recorded,  with  abscesses  of  the 
liver  from  diverticular  abscess  (Whyte^). 

10.  Development  of  Carcinoma. — Secondary  to  diverticulitis. 
Carcinoma    may    result   from    chronic   irritation    and    ulceration    of 

diverticula  due  to  retained  feces  (Hochenegg^). 

11.  Perforation  of  a  Hernial  Sac. — One  case  is  recorded  (Stierlin^). 

^  Ann.  Surg.,  vol.  xi,  p.  523. 
^  Scottish  Med.  and  Surg.,  Jour.  1906. 

'  Verhandlungen  der  Deutsche  Gesellschaft  fur  Chirurg.,  Thirty-first  Congress, 
1902,  p.  402. 

*  Correspondenzbl.  fiir  Schweitzer  Aertze,  IQ02,  vol.  xxxii,  p.  749. 


854  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

Clinical  Aspects. — Patel/  in  discussing  inflammation  of  the  sigmoid, 
classifies  these  conditions  as  acute  non-suppurative  sigmoiditis,  suppura- 
tive perisigmoiditis,  chronic  perisigmoiditis,  sigmoiditis,  and  sigmoiditis 
with  general  peritonitis. 

Inflammatory  trouble,  more  or  less  acute  in  the  left  lower  abdomen, 
has  been  described  as  left-sided  appendicitis,  sigmoiditis,  perisigmoiditis, 
epiploicae  appendicitis,  diverticulitis,  or  peridiverticulitis. 

Clinically,  the  acute  cases  resemble  appendicitis,  except  for  the  fact 
that  the  inflammation  is  on  the  left  side.     The  symptoms  are  as  follows: 

Pain;  constipation;  tenderness  on  pressure;  muscular  rigidity,  espe- 
cially lower  part  of  the  left  rectus,  and  later  tumor;  local  tympanites  is 
present.     Tumor  is  not  always  present. 

Left-sided  Tumor  and  Abscess  Formation. — In  63  cases  tumor  was 
felt  in  20,  and  abscess  formation  occurred  in  23.  In  some  cases  with 
considerable  pus  formation  there  may  be  but  little  pain  and  no  pyrexia 
(Georgi). 

Tumor  is  elongated,  sausage  shaped,  tender,  and  often  ill  defined.  It 
may  be  movable  or  fixed,  lying  a  little  above  Poupart's  ligament  (fre- 
quently parallel  with  it). 

Shortly  after  the  occurrence  of  symptoms,  this  swelling  may  be  made 
out;  it  may  disappear  rapidly  or  gradually,  or  may  increase  with  signs 
of  pus  formation.  Patel  has  shown  that  the  tumor  may  be  higher,  lower, 
or  posterior.  The  position  depends  on  the  location  of  the  inflamed 
diverticulum.  In  a  patient  of  middle  age  or  older  the  diagnosis  of 
diverticulitis  would  be  probable. 

Telling^  now  classifies  the  diverticular  inflammations  in  the  following 
clinical  groups: 

1.  Inflammatory  trouble,  more  or  less  acute  in  the  left  lower  region 
of  the  abdomen  (so-called  left-sided  "appendicitis,"  sigmoiditis,  peri- 
sigmoiditis, epiploic  appendicitis;  diverticulitis;  peridiverticulitis;  peri- 
colitis sinistra,  etc.). 

2.  Perforative  peritonitis. 

3.  Intestinal  obstruction:  Acute,  usually  due  to  involvement  of  the 
small  intestine  by  an  adhesion  producing  kinking  or  strangulation  by  a 
band.     Chronic,  a  mimicry  of  carcinoma. 

4.  Vesicocolic  fistula. 

5.  Inflammatory  trouble  in  the  right  iliac  fossa  or  its  neighborhood. 
This  last  has  been  recently  added  and  will  shortly  be  referred  to. 

Differential  Diagnosis. — Differential  diagnosis  must  be  made  from 
appendicitis,  with  left-sided  symptoms,  pelvic  inflammation,  ovarian 
cyst  with  inflammation  or  strangulation,  actinomycosis  of  the  sigmoid, 
syphilitic  or  tuberculous  pericolitis,  sigmoid  catarrh,  and  dysentery. 
Tuberculosis  is  too  often  accepted.  An  appendix  passing  transversely 
to  the  left  iliac  fossa  can  sometimes  be  determined  by  vaginal  or  rectal 
examination.  Palpation  at  McBurney's  point,  examination  at  Morris' 
point,  and,  in  addition,  of  the  left  lumbar  ganglia,  may  give  some  informa- 
tion.    The  determination  of  the  appendix  Head  zone  may  also  be  of  assist- 

'  Revue  de  Chir.,  Oct.  10,  1907,  and  Dec.  10,  1907. 
*  The  Proctologist,  March,  191 1. 


DIVERTICULITIS' — PERIDIVERTICULITIS  855 

ance.  An  abnormal  position  of  the  cecum  occasionally  occurs.  With 
tuberculosis,  bacilli  may  be  found  in  the  stools,  also  pus  and  blood,  but 
not  always  at  first.  The  tuberculin  reaction,  ocular  or  by  injection,  aids 
diagnosis.  Pus  and  blood  appear  in  dysentery  and  syphilis,  and  the 
Ameba  or  Bacillus  dysenteriae  in  the  former  and  Wassermann's  reaction 
in  the  latter.  Mucus  alone  is  present  in  catarrh.  Actinomyces  are 
found  in  the  stool  in  actinomycosis.  Vaginal  examination  helps  diagnose 
pelvic  conditions. 

Sigmoiditis. — The  writer  classifies  catarrh  of  the  sigmoid  as  a  colitis 
(acute  or  chronic)  of  catarrhal  type,  involving  this  portion  of  the  colon 
or  as  "catarrhal  sigmoiditis."  True  sigmoiditis  Patel  defines  as  a  diffuse 
inflammation.  In  some  cases  there  may  be  acute  inflammatory  changes 
not  involving  the  entire  wall  of  the  bowel,  which  may  yield  to  the  external 
application  of  ice  and  enemata.  In  other  cases  the  entire  thickness  of 
the  bowel  is  involved,  and  there  may  be  local  signs  with  tumor  formation, 
fever,  etc.  These  last  cases  may  be  acute,  subacute,  or  chronic.  At 
times  the  inflammation  may  subside  in  any  of  these  types.  The  writer 
believes  a  diverticulum  or  diverticula  are  responsible  for  these  cases,  and 
that  they  correspond  to  diverticulitis  and  peridiverticulitis. 

Intestinal  Obstruction. — When  acute,  this  is  probably  due  to  secondary 
involvement  of  a  coil  of  small  intestine,  and  the  diverticulitis  frequently 
cannot  be  diagnosed  except  at  operation. 

The  same  is  true  of  chronic  obstruction  of  the  small  intestine.  Obstruc- 
tion, which  is  chronic,  recurrent,  or  acute  engrafted  on  chronic,  when 
localized  in  the  sigmoid  region  -is  nearly  always  diagnosed  as  the  result 
of  carcinoma,  when  it  occurs  in  an  elderly  person  with  a  history  of 
constipation. 

Advanced  age,  more  recent  constipation,  cachexia,  and  blood  in  the 
stools  favor  cancer;  while  long-standing  constipation,  absence  of  blood 
in  the  stools  after  repeated  examinations,  and  slight  cachexia  (or,  rather, 
loss  of  weight),  together  with  an  evidence  of  pus  formation,  would  favor 
peridiverticulitis. 

Entire  absence  of  constipation  may  occur  with  either,  and  blood  has 
been  found  in  one  diverticular  case.  Probably  many  of  the  so-called 
cases  of  cancer  are  really  this  condition. 

X-rays. — With  progressive  stenosis  the  :i:-rays  are  of  value  in  locating 
the  position  of  the  lesion.  There  is  an  accumulation  of  barium  or  bis- 
muth (administered  per  oram)  above  the  stenosed  region  and  by  enema 
the  narrowing  and  interference  with  passage  of  bismuth  readily  appear  in 
the  radiograph.  Diverticula  may  also  be  demonstrated  in  the  chronic 
cases,  and  may  appear  in  the  radiographs  taken  for  diagnosing  other 
lesions.     The  a;-ray  should  never  be  employed  in  acute  cases. 

Perforative  Peritonitis. — In  these  cases  a  routine  examination  of  the 
sigmoid  should  be  made.  It  some  cases  there  may  be  a  previous  history 
of  left-sided  abdominal  inflammation,  but  in  others  there  is  no  such 
history. 

Vesicocolic  Fistula. — Probably  many  of  these  cases,  supposedly  due 
to  cancer  of  the  sigmoid,  are  the  result  of  diverticulitis  with  adhesions 
and  perforation  of  the  bladder.     Air  and  feces  pass  through  the  urethra. 


856  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

Cripps  found  45  cases  of  vesico-intestinal  fistula  out  of  63  to  be  inflamma- 
tory, only  9  cancerous,  and  some  of  these  doubtful. 

There  seems  to  be  a  liability  of  postoperative  peritonitis  following  an 
operation  for  diverticulitis,  probably  from  other  thin-walled  diverticula. 

Inflammatory  Lesions  on  the  Right  Side  of  the  Abdomen. — Diverticula 
may  sometimes  occur  throughout  the  colon  and  are  found  in  the  cecum. 
Taylor  and  Lakin^  report  perforation  of  a  diverticulum,  5>^  inches  from 
the  cecum.  This  possibility  must  always  be  considered;  i.e.,  in  some  cases 
which  may  simulate  an  inflamed  appendix,  the  cause  may  be  a  diverticulum. 

Diagnosis. — To  recapitulate:  Diverticulitis  occurs  usually  in  persons 
over  thirty-five  years  of  age  suffering  from  constipation  and  of  obese  habit. 
The  site  of  pain  about  corresponds  on  the  left  side  to  that  of  appendicitis 
on  the  right.  Muscular  rigidity,  especially  of  the  left  rectus,  is  present. 
There  is  tenderness  on  pressure  in  the  left  iliac  fossa.  Tumor  may  or 
may  not  be  present. 

In  suppurative  cases  there  may  be  chills.  Leukocytosis  is  present. 
The  increase  in  the  polynuclears  and  hyperinosis  are  of  importance  for 
diagnosis. 

The  various  types  have  been  described;  among  the  most  common  are 
acute  peritonitis,  resulting  from  perforation;  local  abscess,  which  may 
break  into  some  viscus,  as  the  bladder,  or  which  must  be  opened ;  acute  or 
chronic  obstruction,  resulting  from  stenosis  of  the  sigmoid  from  peri- 
diverticulitis; chronic  tumors,  simulating  carcinoma;  and  milder  cases, 
with  local  pain,  tenderness,  constipation;  and  a  local  tumor,  which 
symptoms  gradually  subside  under  treatment. 

Treatment. — The  acute  cases  should  receive  the  same  treatment 
as  acute  appendicitis.  In  mild  cases  the  bowel  should  be  emptied  by 
enema;  liquid  diet,  preferably  broths  and  gruels;  ice-bag  continuously 
applied;  absolute  rest  in  bed.  Subsequent  attention,  after  recovery, 
should  be  directed  to  the  careful  regulation  of  the  bowels  by  diet  and 
medication.  Intestinal  irrigation  and  high  olive  oil  injections  also  are  of 
value.  Cases  of  chronic  stenosis  may  be  temporarily  treated  as  such. 
Indications  for  operation  are  the  same  as  in  appendicitis. 

Acute  obstruction,  peritonitis,  and  abscess  require  immediate  opera- 
tion. Chronic  obstruction  may  require  resection.  Appropriate  operative 
procedures  are  necessary  for  the  complications  described. 

MECKEL'S  DIVERTICULUM  AND  ITS  DISEASES 

The  persistence  of  this  organ  in  some  form  is  found  in  i  to  2  per  cent, 
of  all  persons  and  more  frequently  in  males.  As  a  rule  it  gives  rise  to 
no  symptoms.  Disease  of  this  organ  is  believed  by  some  to  occur  most 
frequently  in  childhood,  while  others  believe  it  to  be  most  frequent  in 
adult  life,  the  average  age  being  about  twenty-one.  Strangulation  of 
the  intestine  by  the  diverticulum  or  its  remains,  is  the  most  frequent 
lesion  and  is  described  under  acute  intestinal  obstruction.  The  diver- 
ticulum may  also  become  strangulated  by  the  ileum.  The  diverticulum 
may  persist  and  open  at  the  umbilicus  with  resulting  fecal  fistulae.  There 
*  Lancet,  Feb.  19,  1910,  p.  495. 


DIVERTICULITIS — PERIDIVERTICULITIS  857 

may  be  two  lateral  openings  and  occasionally  the  intestine  may  protrude 
and  become  strangulated.  The  diverticulum  may  become  obstructed 
at  both  ends  and  a  cystic  tumor  form  or  concretions  may  be  present 
and  a  communication  be  found  between  the  intestine  and  bladder.  Super- 
involution  may  occur,  resulting  in  a  narrowing  of  the  intestine;  the 
obliterating  process  in  the  diverticulum  has  passed  into  the  intestine  in 
such  event.  Rarely  invagination  of  the  diverticulum  occurs,  which  is 
liable  to  be  followed  by  an  ileocecal  intussusception.  The  average 
age  of  these  cases  is  said  to  be  about  thirteen  years,  a  contrast  to  the  early 
age  of  other  cases  of  intussusception.  Complete  obstruction  may  not 
follow  a  partial  invagination  but  hemorrhage  of  slight  or  severe  type  ensue. 
Volvulus  of  the  diverticulum  may  rarely  occur  though  that  of  the  ileum 
is  usually  associated  with  it,  especially  if  the  distal  end  of  the  process  is 
attacked.  Hernia  of  this  process,  both  inguinal  and  femoral,  more 
frequently  the  latter,  has  been  reported. 

Inflammation  of  Meckel's  Diverticulum. — This  condition  has  also 
been  described  as  "diverticulitis"  and  it  may  be  primary  or  secondary. 
In  the  latter,  another  lesion  first  develops,  such  as  obstruction  of  the 
ileum  by  the  diverticulum  and  then  obstruction  of  the  diverticulum, 
with  subsequent  inflammation,  or  the  diverticulum  may  become  stran- 
gulated in  a  hernial  sac. 

Primary  Diverticulitis. — With  primary  divertictditis  there  are  acute, 
and  chronic,  or  recurring  cases. 

Etiology. — The  chief  source  is  infection.  Previous  digestive  dis- 
turbances or  traumatism  may  be  factors.  Among  other  causes  are  foreign 
bodies,  intestinal  parasites  and  rarely  tj^hoid  ulcer. 

Age. — It  may  occur  at  all  ages — about  33  per  cent,  in  children  and  the 
balance  from  twenty  to  seventy  years. 

Pathology. — There  are  all  grades  of  inflammation  from  simple  catarrh 
to  gangrene  with  a  local  or  general  peritonitis,  resembling  appendicitis. 
Perforation  of  a  typhoid  ulcer  may  occur  without  gangrene. 

Symptoms. — These  vary  considerably.  With  subacute,  chronic  or 
recurring  cases,  there  are  gastric  disturbances,  constipation  and  recurring 
attacks  of  pain  in  the  region  to  the  right  of  the  umbilicus  or  in  the  right 
iliac  fossa.  With  acute  cases  or  acute  exacerbation  of  the  chronic,  acute 
appendicitis  may  be  closely  simulated  except  that  the  pain  is  usually 
higher  and  nearer  the  umbilicus.  There  are  abdominal  tenderness  in 
this  region,  muscular  rigidity  and  finally  dulness  on  percussion,  also  nausea, 
vomiting,  rise  of  temperature,  leukocytosis  and  increase  in  the  poly- 
nuclears.  Constipation  is  a  frequent  symptom  though  diarrhea  occurs 
fairly  often.  In  the  subacute  or  chronic  cases  intestinal  hemorrhage 
may  occur.  Local  or  general  peritonitis  may  result.  Intestinal  ob- 
struction may  become  complete  from  compression,  inflammatory  adhe- 
sions or  kinking;  constipation  is  liable  to  occur  from  kinking  of  the 
intestinal  coils  involved  in  a  local  peritonitis  or  from  intestinal  paresis. 
With  secondary  diverticulitis  intestinal  obstruction  may  first  occur  with 
diverticulitis  later  associated  with  a  local  or  general  peritonitis. 

Diagnosis. — So  far  correct  diagnosis  has  not  been  made  but  the  con- 
dition  has   been    attributed    to   appendicitis.     Since    the    diverticulun? 


858  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

may  originate  from  the  ileum  from  i  to  3  feet  above  the  ileocecal  valve  and 
the  ileum  is  very  movable,  its  position  in  the  abdominal  cavity  is  variable 
and  its  localization  not  fixed.  The  pain  and  tenderness,  however,  are 
not  so  often  at  McBurney's  point,  but  generally  higher  and  to  the 
right  of  the  umbilicus,  or  even  above  it,  though  occasionally  in  some  dif- 
ferent region.  There  is  an  area  of  puffiness  or  firm  resistance  at  the  site 
of  inflammation  and  an  absence  or  only  a  slight  degree  of  meteorism  early 
in  the  attack.  Blood  is  present  in  the  stools  and  at  times  in  the  vomitus. 
Gastric  disturbances,  local  attacks  of  pain  constipation  or  diarrhea,  rise 
of  temperature,  leukocytosis  and  increased  polynuclears  occur.  There 
may  be  an  earlier  existence  of  an  umbilical  fistula  or  some  malformation 
elsewhere  in  the  body. 

Prognosis. — Recovery  in  catarrhal  cases  has  never  been  recognized 
as  such  during  hfe,  though  postmortem,  when  dying  from  an  intercurrent 
disease,  it  has  been  demonstrated  that  it  has  occurred.  The  prognosis  is 
unfavorable  40  to  65  per  cent,  mortality  in  acute  cases. 

Treatment.— Ivamedidite  operation  is  indicated.  If  Meckel's  diver- 
ticulum be  found  at  any  abdominal  operation,  it  should  be  removed. 


CHAPTER  XXXIII 
INTESTINAL  OBSTRUCTION— ACUTE  AND  CHRONIC 

Intestinal  obstruction  occurs  in  two  types — acute  and  chronic. 
Acute  obstruction  is,  in  turn,  characterized  by  two  anatomic  types: 

1.  Acute  intestinal  obstruction  with  sudden  complete  occlusion  of 
the  intestinal  lumen. 

2,  Acute  intestinal  obstruction  engrafted  suddenly  on  a  chronic 
obstruction  (chronic  stenosis),  due  to  a  sudden  blocking  of  the  stenosed 
intestines  from  various  causes,  such  as  by  a  foreign  body  or  a  fecal  accu- 
mulation above  the  stricture. 

ACUTE  INTESTINAL  OBSTRUCTION 

{Synonyms. — Ileus;  Miserere;  Passio  Iliaca) 

General  Considerations. — Acute  intestinal  obstruction  may  be 
defined  as  a  sudden  acute  stoppage  of  the  passage  of  the  intestinal  con- 
tents. This  may  be  caused  by  mechanical  occlusion  of  the  intestinal 
canal  (mechanical  ileus),  by  a  sudden  loss  of  motor  power  in  a  portion 
or  in  all  the  bowel  (dynamic  or  paralytic  ileus),  or  by  a  combination  of 
these  conditions. 

Before  discussing  the  matter  further,  as  a  means  of  assistance  to  diag- 
nosis, I  wish  to  call  a  few  very  important  facts  to  my  reader's  attention. 

As  a  rule,  we  may  say  that  acute  obstruction  of  the  small  intestine 
gives  rise  to  more  severe  and  violent  symptoms  than  that  of  the  large 
intestine.  The  nervous  apparatus  of  the  small  intestine  is  in  connection 
with  most  important  plexuses,  the  solar  and  superior  mesenteric,  and 
the  pain  is  more  violent,  the  vomiting  earlier  and  more  marked,  and  the 
prostration  and  shock  more  rapid. 

Various  explanations  have  been  advanced  for  the  marked  toxemia 
occurring  with  strangulation  of  the  small  intestines.  Draper  has  dem- 
onstrated that  life  is  prolonged  in  animals  in  whom  this  condition  has 
been  artificially  produced,  by  feeding  with  the  intestinal  cells  of  the 
small  intestines,  so  that  it  would  seem  that  their  destruction  by  stran- 
gulation has  apparently  some  influence  in  the  production  of  the  toxemic 
symptoms. 

The  early  appearance  of  indicanuria  and  of  anuria  are  also  significant 
of  obstruction  in  the  small  intestine. 

Moreover,  simple  occlusion  of  the  intestines  does  not  lead  to  nearly 
as  acute  symptoms  as  when  strangulation  is  present.  In  the  latter 
condition  interference  with  the  circulation  of  the  intestinal  wall  and  of 
the  mesentery  and  the  irritation  of  the  sensory  nerves  give  rise  to  acute 
and  violent  symptoms,  marked  pain,  vomiting,  and  shock.  In  this  class 
of  cases  we  have  the  acute  internal  hernias  and  strangulations,  volvulus, 

859 


86o  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

and  the  severe  type  of  acute  intussusception.  Local  meteorism  is  gen- 
erally present  in  the  early  stages  of  volvulus,  internal  herniaform  strangu- 
lation and  kinking  of  the  bowels,  and  enables  us  at  times  to  locate  the 
character  of  the  lesion.  Often  this  distention  rapidly  becomes  very 
extensive,  as  in  volvulus,  for  example,  a  general  distention  ensues,  so  that 
determination  of  the  condition  is  difficult. 

In  the  majority  of  cases  of  acute  obstruction  when  we  find  present 
marked  increased  peristaltic  movements  of  the  bowel,  with  stiffening 
and  rigidity  of  loops  of  intestines;  they  occur  in  acute  cases  engrafted 
on  cases  of  chronic  stenosis  with  hypertrophy  of  the  bowel  muscle  above 
the  stricture.  We  occasionally  see  this  symptom  in  primary  acute 
conditions,  especially  in  acute  intussusception. 

We  must  remember,  moreover,  that  acute  dilatation  of  the  stom- 
ach, either  alone  or  associated  with  intestinal  paresis,  quite  frequently 
occurs  after  operation,  and  presents  many  of  the  symptoms  of  acute 
dynamic  ileus.  There  is  obstruction,  in  fact,  in  many  cases  due  to 
pressure  of  the  organ  on  the  transverse  duodenum  or,  as  some  believe, 
by  mesenteric  traction.  The  stomach  may  occupy  the  left  half,  or 
even  the  entire  abdominal  cavity.  I  have  referred  to  this  condition 
under  Acute  Dilatation  of  the  Stomach. 

Practically  we  may  say  that  in  every  case  of  acute  obstruction, 
intra-abdominal  tension  is  markedly  increased,  thus  interfering  with 
the  physical  examination.  I  place  the  following  suggestions  at  the 
commencement  of  this  chapter  in  order  to  emphasize  them  the  more. 
They  are  of  value  as  an  aid  to  diagnosis  in  every  case  with  acute  symptoms. 

Immediate  and  thorough  lavage,  digital  examination  of  the  rec- 
tum, and  if  no  evidences  therein  of  obstruction  or  intussusception,  pre- 
venting the  entrance  of  an  injection,  then  a  careful  recurrent  rectal 
irrigation;  vaginal  examination  and  inspection  of  hernial  openings  should 
be  the  preliminaries  in  the  examination  of  every  case.  Lavage  and 
irrigation  of  the  bowel  immediately  promote  the  comfort  of  the  patient 
by  lessening  distention,  render  the  physical  examination  easier,  and  the 
combined  methods  are  thus  an  invaluable  aid  to  diagnosis.  It  may  be 
necessary  to  substitute  a  high  enema  for  irrigation. 

Etiology  of  Acute  Intestinal  Obstruction. — The  various  causes  of 
acute  intestinal  obstruction,  on  account  of  their  importance,  will  now 
be  considered  separately: 

The  first  classification  that  I  shall  describe  is  the  so-called  internal 
herniaform  strangulation  of  the  bowel  (compression  of  the  intestines), 
due  to  strangulation  by  (a)  bands  and  adhesions,  the  result  of  a  former 
peritonitis;  {b)  Meckel's  diverticulum;  (c)  slits  and  apertures;  {d)  in- 
carceration into  herniae;  (e)  tumor  pressure  from  without. 

Frequency. — Fitz,  in  an  analysis  of  295  cases  of  acute  obstruction, 
gives  34  per  cent,  of  the  cases  as  due  to  this  type  of  strangulation  (internal 
herniaform),  excluding  volvulus;  35  per  cent,  out  of  1134  cases  are  reported 
by  Leichtenstern. 

Out  of  loi  cases  of  strangulation  Fitz  shows  that  63  were  due  to 
adhesions  and  bands,  and  21  to  vitelline  remains. 

Strangulation  of  the  intestines  by  adhesions  and  bands  thus  con- 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  86 1 

stitutes  the  largest  percentage  of  this  class.  In  some  cases  they  may  be 
congenital.  The  band  may  be  a  firm  fibrous  cord,  or  may  be  tough  and 
thin  as  a  thread,  occasionally  it  may  be  ^-^  inch  wide. 

Strangulation  from  bands  and  adhesions  may  occur  in  four  ways: 

1.  There  may  be  a  short  tense  band  firmly  attached  at  each  end, 
beneath  whose  arch  a  knuckle  of  the  intestines  passes,  the  space  may 
only  be  of  a  size  to  admit  two  or  three  fingers. 

2.  On  the  other  hand,  there  may  be  a  long  lax  band,  attached  at 
its  ends  and  forming  a  ring  or  spiral  8,  through  which  a  loop  of  the  small 
intestine  may  slip. 

3.  A  loop  of  intestines  filled  with  contents  may  lie  over  a  tense  band 
of  adhesions  and  thus  become  strangulated;  this  is  a  rare  occurrence, 
but  has  been  described  by  Treves. 

4.  The  intestines  may  suddenly  become  kinked  and  occluded  by 
traction  from  an  adhesive  band,  as  if  an  ovarian  cyst  were  tapped  and 
the  sudden  contraction  drew  on  an  adhesion  to  the  intestines. 

These  bands  and  adhesions  may  occur  between  any  of  the  viscera, 
the  parietal  peritoneum,  omentum,  and  mesentery. 

Adhesions  may  surround  the  bowel  and  contract,  narrowing  its  lumen, 
also  a  mesenteric  contraction  may  be  a  cause. 

A  coil  may  be  caught  between  the  pedicle  of  a  tumor  and  the  pelvic 
wall  or  may  circumscribe  a  tumor  pedicle. 

Strangulation  by  Meckel's  Diverticulum. — ^Meckel's  diverticulum  is 
due  to  the  incomplete  obliteration  of  the  vitelline  duct,  and  forms  a 
finger-like  projection  from  the  ileum,  usually  within  18  inches  from 
the  ileocecal  valve.  As  a  rule,  it  is  about  3  inches  long,  though  fre- 
quently longer,  and  cylindric  in  shape  with  a  conic  end,  though  the 
latter  is  occasionally  "clubbed."  The  end  may  become  attached  to 
the  abdominal  wall  near  the  navel,  to  the  mesentery,  or  to  some  other 
point,  and  thus  form  a  band  or  loop  under  which  strangulation  may 
occur.  More  often  the  diverticulum  is  free  and  may  form  a  ring  into 
which  its  end  projects.  A  loop  of  the  intestines  may  enter  the  ring  and, 
especially  if  the  tip  is  club  shaped,  may  push  it  before  it  and  tie  a  knot 
(Fig.  343). 

The  vermiform  appendix  may  become  adherent  to  some  point  in 
the  peritoneal  cavity  and  from  an  arch  under  which  a  loop  of  the  intestines 
may  become  strangulated.  This  may  likewise  occur  with  the  Fallopian 
tube. 

Strangulation  of  the  Bowel  through  Slits  and  Apertures.— This  type 
is  less  often  met  with,  and  is,  in  fact,  quite  rare.  Slits  and  apertures 
in  the  mesentery  and  omentum  may  be  congenital,  but  are  more  fre- 
quently traumatic.  They  generally  occur  in  the  mesentery  near  the 
lower  part  of  the  ileum.  Fissures,  holes,  or  rings  are  more  frequently 
formed  by  peritoneal  adhesions;  more  rarely  strangulation  may  occur  in  a 
tear  of  the  uterus  or  bladder. 

Strangulation  from  Internal  Hernice. — These  are  situated  within 
the  abdominal  or  thoracic  cavity,  or  are  subperitoneal  or  retroperitoneal, 
parallel  to  the  abdominal  wall  without  passing  outward. 

In  some  of  the  so-called  external  herniae  no  swelling  can  be  detected 


862 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


externally.  Moreover,  hernia  may  develop  in  an  accessory  form  between 
the  muscles  and  fascia. 

Among  internal  herniae  we  may  have  those  of  the  recessus  duodeno- 
jejunalis,  intersigmoid  recess,  retroperitoneal,  anterior,  retrocecal,  fora- 
men of  Winslow,  and  diaphragmatic  (Figs.  344-346). 

Diaphragmatic  hernia  is  most  frequently  met  with  of  these  forms 
and  can  occasionally  be  diagnosed.     It  has  previously  been  described. 

It  may  be  congenital  or  traumatic,  as  from  wounds,  contusions,  or 
excessive  vomiting. 


Fig.  343- 


-Knotting  of  a  Meckel's  diverticulum  which  has  a  button-like  swelling  of  its 
extremity  (after  Treves). 


In  the  true  form,  a  hernial  sac  of  peritoneum  or  pleura  covers  the 
viscera;  in  the  false  form  (the  more  frequent)  it  does  not.  This  type 
is  found  on  the  left  side,  the  stomach  being  involved  most  frequently,  the 
colon  and  small  intestine  less  so. 

The  stomach  fundus  passes  into  the  thorax  and  apical  rotation  occurs. 

Physical  Signs  of  Diaphragmatic  Hernia. — Pneumothorax,  less  motility 
of  the  side  of  thorax  involved,  bulging  of  the  walls  of  the  thorax,  and 
metallic  sounds  are  the  chief  symptoms.  Dyspnea,  distress  or  pain  in 
the  thorax,  and  difficulty  in  swallowing  (dysphagia)  may  be  present. 
Diaphragmatic  hernia  can  be  diagnosed  by  inflation  of  the  stomach  with 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC 


863 


air  or  water,  the  use  of  the  a;-ray,  or  by  gastrodiaphany.     See  section  on 
this  subject. 

Mechanism  of  Internal  Herniaform  Strangulation  {Compression  of 
the  Intestines). — The  mechanism  of  the  type  of  obstruction  just  described 
is  as  follows: 

A  coil  of  gut  is  drawn  beneath  a  band  or  through  an  aperture,  and 
becomes  at  once  strangulated,  or  con- 
gestion of  the  mesenteric  vessel  occurs, 
then  gas  and  pus  accumulate,  and  later 
strangulation  occurs,  or,  in  addition,  a 
torsion  of  the  bowel  may  take  place — 
necrosis,  gangrene,  and  perforation  result. 

The  lower  part  of  the  ileum  is  chiefly 
affected.  Peritonitis  may  occur  early,  in 
twenty-four  hours,  or  late,  in  one  to  two 
weeks.  Various  types  of  strangulation 
are  shown  in  Figs.  347-354. 

Sex  and  Occurrence. — In  males  70  per 
cent.,  though  some  claim  occurrence  in 
the  sexes  is  equal.  Between  twenty  and  forty  years  cases  chiefly  occur, 
though  40  per  cent,  are  between  fifteen  and  thirty  years.  In  90  per 
cent,  the  seat  of  the  trouble  is  in  the  small  intestine,  usually  the  ileum; 
in  67  per  cent,  strangulation  is  in  the  right  iliac  fossa;  in  83  per  cent.,  in 
the  lower  abdomen  (Osier). 

Clinical  Symptoms. — These  are  characterized  by  their  sudden  acute 
onset  while  the  patient  is  in  perfect  health.     Rarely  injury,  violent  move- 


Fig.  344. — A  rod  in  the  ileo- 
pendicular,  or  ilapeocecal,  fossa 
(Cantlie). 


Fig.  345. — The  intersigmoid  tossa  exposed 
by  holding  upward  the  pelvic  colon;  the  double 
dotted  line  indicates  the  ureter  behind  the  peri- 
toneum (Cantlie). 


Fig.  346. — A   rod   in  the  ileocolic 
fossa  (Cantlie). 


ment,  or  diarrhea  may  precede  the  attack,  and  are  considered  to  be 
factors.  Sudden  severe  pain  first  occurs,  occasionally  colicky,  often 
severe  throughout,  though  at  the  end  it  may  lessen.  The  pain  at  times 
corresponds  to  the  seat  of  the  strangulation.  Vomiting  begins  early  and 
is  persistent  and  soon  becomes  feculent;  absolute  constipation  is  present, 
no  flatus  is  passed.     There  is  early  and  rapid  appearance  of  collapse. 


864 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


Fig.  347. — A  band  in 
the  form  of  a  loop  attached 
to  the  intestine  and  mesen- 
tery (Cantlie). 


Fig.  348. — The  coil  of 
intestine  has  slipped 
through  the  loop  of  Fig. 
347,  and  caused  strangu- 
lation by  a  complicated 
knot  (Cantlie). 


Fig.  349. — A  coil  of  in- 
testine, in  addition  to  being 
snared  under  a  band,  has 
undergone  rotation  on  its 
mesenteric  axis   (Cantlie). 


Fig.  350. — A  knuckle  of  intestine 
snared  over  a  band  which  is  stretehing 
from  the  intestine  to  the  mesentery 
(Cantlie). 


Fig.  351. — A  knuckle  of  intestine  snared 
by  a  band  which  has  assumed  the  form  of  a 
simple  loop    (Cantlie). 


Fig.  352. — A  knuckle  of  intestine 
snared  under  a  band  which  is  stretch- 
ing from  the  intestine  to  the  mesentery 
(Cantlie). 


Fig-  353- — A.  coil  of  small  intestine  ad- 
herent to  a  caseating  tuberculous  mesen- 
teric gland  (Cantlie). 


Fig.  354. — .\  band  attached  to  the 
small  intestine  and  umbilicus^  causing 
an  acute  kink  of  the  bowel  (Cantlie). 


INTESTINAL    OBSTRUCTION — ACUTE    AND    CHRONIC 


86s 


urine  Is  scanty,  meteorism  slight  or  absent,  slight  tenderness  on  pressure, 
no  blood  in  bowel  movements  if  such  occur,  nor  is  it  discoverable  by 
enema.      Death  occurs  in  two  to  four  days. 

If  peritonitis  occurs,  meteorism  is  marked  and  pain  recurs  and  is 
severe.  A  circumscribed  area  of  dulness  or  tumor  is  rare.  The  attack 
is  of  a  fulminating  character. 

Volvulus  may  be  defined  as  an  obstruction  of  the  bowel  caused  by  a 
rotation  of  the  intestines  about  their  axis,  a  rotation  of  the  bowel  about 
its  mesentery,  or  an  intertwining  (rotation)  or  knotting  of  two  intestinal 
loops  with  their  mesenteries. 

It  occurs  most  frequently  in  the  sigmoid  flexure.  The  ascending 
colon,  cecum,  and  small  intestine,  especially  the  ileum,  may  sometimes  be 
affected,  and  intertwining  of  the  intestines  is  most  often  met  with  in 
this  location. 

Mechanics. — The  Sigmoid  Flexure. — The  sigmoid  flexure  must  be 
large  and  its  mesocolon  long  and  narrow  for 
the  development  of  volvulus.  The  ends  of  the 
sigmoid  are  thus  approximated,  and  it  can 
readilv  rotate  around  the  mesocolon  as  a  pedicle 


Fig.  355 —Illustrating 
the  disposition  of  a  loop  of 
bowel  which  is  predisposed 
to  volvulus.  The  parietal 
attachment  of  the  mesen- 
tery is  considerably  shorter 
than  its  intestinal  attach- 
ment, and  the  coil  is,  as  it 
were,  suspended  os  from  a 
pedicle  (Cantlie). 


Fig.  356. — Illustrating 
a  volvulus  in  which  the 
upper  segment  of  intestine 
passes  in  front  of  the  lower 
one  (Cantlie). 


Fig.  357- — Illustrating 
a  volvulus  in  which  the 
upper  segment  of  intestine 
passes  behind  the  lower 
one  (Cantlie). 


(Fig.  355).     This  condition  may  be  congenital  or  due  to  some  chronic 
inflammation. 

Etiology. — Chronic  habitual  constipation  is  the  chief  cause,  as  the 
weight  of  the  fecal  matter  produces  local  displacement  and  distorts  and 
elongates  the  mesentery. 

The  rotation  is  usually  the  result  of  bodily  exertion.  On  the  other 
hand,  one  branch  of  the  flexure,  being  over  distended,  may  drop  down  over 
the  other.  The  branches  may  be  rotated  through  180  to  360  degrees,  or 
even  several  complete  rotations  may  occur.  The  distention  of  the 
sigmoid,  the  congestion  and  exudation  of  fluid  and  accumulation  of  gas 
in  the  loop,  prevent  restitution  to  the  normal  position.  The  accumulation 
of  gas  in  the  colon  also  prevents  return  to  normal.  Volvulus  is  illustrated 
in  Figs.  356  and  357. 

Small  Intestine. — -The  same  conditions  favor  axial  rotation  of  the  small 
intestine. 

Inflammation  of  the  mesentery  is  sometimes  a  cause,  also  gall-stones, 
by  producing  colic  and  spasm. 
55 


866  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

Accessory  Causes. — ^Leanness,  the  absence  of  fat  in  the  mesentery, 
and  hence  lessened  intra-abdominal  pressure  have  been  considered  pre- 
disposing causes,  also  trauma,  jumping  and  lifting,  sudden  diarrhea 
(peristalsis)  in  these  constipated  cases,  or  a  large  enema  (according  to 
some). 

Age. — It  is  more  common  in  older  than  in  young  objects,  generally  in 
those  over  forty  years  of  age,  though  Fitz  places  it  more  frequently  at 
thirty  to  forty  years  in  his  statistics. 

Frequency. — Fitz  finds  42  out  of  295  cases  of  acute  intestinal  obstruction 
due  to  volvulus. 

Sex. — According  to  Fitz  it  is  more  frequent  in  men — 68  per  cent.  Some 
place  the  proportion  much  higher,  as  three  or  four  men  to  one  woman. 

Symptoms. — This  condition  is  characterized  by  its  acuteness  and  rapid 
course.  It  is  more  rapid  than  any  other  form,  except,  possibly,  internal 
strangulation  of  the  intestines. 

Pain  is  sudden,  violent,  and  never  absent,  and  sometimes  localized 
in  the  left  lower  quadrant;  it  may  remit,  but  there  is  never  a  complete 
intermission.  Vomiting  is,  as  a  rule,  violent  and  profuse,  continuous, 
and  is  an  early  symptom,  though  occasionally  less  frequent  in  sigmoid 
volvulus.  Fecal  vomiting  is  comparatively  rare.  Constipation,  both  for 
feces  and  flatus,  occurs,  as  a  rule,  from  the  incipiency  of  the  attack.  Occa- 
sionally a  history  of  violent  exercise  or  of  acute  diarrhea  may  precede  the 
attack.  Tenesmus  may  be  present  in  volvulus  of  the  sigmoid,  though 
not  as  frequent  as  in  intussusception,  and  in  rare  instances  there  is  the 
passage  of  a  small  amount  of  blood. 

Local  meteorism  is  an  important  symptom,  /Ae  left  lower  portion  of 
the  abdomen  protrudes  as  a  tense  and  elastic  swelling,  feeling  like  a  rubber 
ball;  visible  peristaltic  movements  do  not  occur;  percussion  may  be 
tympanitic,  there  may  be  metallic  sounds,  or  rarely,  dulness  if  there  is 
much  edema.  In  some  cases  there  is  an  S-shaped  protrusion  of  the 
abdomen,  most  prominent  in  the  upper  left  and  lower  right  quadrant. 
This  is  in  the  early  stages.  General  meteorism  develops  most  rapidly, 
next  in  rapidity  to  that  of  general  peritonitis,  but  in  the  latter  the  abdomen 
is  very  tender;  while  in  the  former  it  is  only  slightly  so.  Within  forty- 
eight  hours  the  abdomen  may  be  balloon  shaped.  This  rapid  meteorism 
is  an  aid  to  diagnosis. 

The  symptoms  are  very  acute  and  collapse  is  marked.  In  axial  rota- 
tion of  the  small  intestine  at  the  onset  there  may  not  be  absolute  consti- 
pation; the  local  meteorism  starts  higher  up  and  there  is  no  tenesmus. 
In  these  cases,  curiously  enough,  the  symptoms  are  no  more  violent  than 
in  sigmoid  volvulus. 

Anatomy. — There  is  local  meteorism,  the  walls  of  the  distended  loop 
are  thickened,  rigid,  edematous,  and  dark  red.  The  peritoneal  coat  is 
often  torn,  as  is  the  muscularis.  Hemorrhages  are  seen  in  the  intestinal 
wall.  Blood,  gas,  mucus,  and  feces  lie  in  the  loop.  The  mesentery  is 
hyperemic  and  infiltrated.  The  twisted  part  of  the  intestines  is  attenu- 
ated and  pale.  Gangrene  may  occur  at  the  line  of  demarcation.  Other 
parts  of  the  intestines  are  collapsed  and  pale  unless  general  meteorism 
subsequently  occurs. 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC 


867 


Course. — The  course  of  volvulus  is  always  acute.  The  patients  may 
occasionally  die  in  twelve  to  twenty-four  hours  or  in  two  to  three  days; 
the  average  course  is  a  week.  They  die  of  collapse,  exhaustion,  peritonitis, 
or  from  paralysis  of  the  heart  due  to  compression  from  tympanites. 
Unless  operation  is  performed,  the  cases,  as  a  rule,  are  fatal,  especially 
those  with  complete  axial  rotation. 

Some  patients  who,  from  the  symptoms,  seem  to  have  suffered  from 
partial  rotation,  the  course  being  more  chronic,  have  recovered. 

Intussusception;  Invagination. — It  is  in  this  condition  that  one  seg- 
ment of  the  intestines  slips  into  an  adjacent  segment,  so  that  the  latter 
forms  a  sheath  for  the  former.  The  two  portions  make  a  cylindric  tumor 
which  varies  in  length  from  an  inch  to  many  feet.  The  condition  is 
always  a  descending  intussusception.  The  outer  tube  is  called  the  sheath 
or  intussuscipiens;  the  middle  and  inner  tubes,  the  intussusceptum ;  the 
innermost  tube,  the  entering  tube;  the  middle  one,  the  returning  tube 


/TJ-Az/vr/rtj-    ^^T"'"V 


Fig.  358. — Intussusception. 


Fig.    359. — An    in-  Fig.  360. — An  intus- 

tussusception      (Cant-      susception   in  longitudi- 
lie).  nal  section:  A,  The  en- 

tering layer;  B,  the  re- 
turning layer;  C,  the 
sheath  (Cantlie). 


(Figs.  358-360).  The  upper  part,  where  the  middle  tube  bends  over  into 
the  sheath,  is  called  the  neck;  its  lower  part,  where  the  inner  tube  bends 
over  into  the  returning  cylinder,  is  called  the  head.  Mucous  membrane 
is  in  contact  with  mucous  membrane  and  peritoneum  with  peritoneum. 
Those  depicted  are  the  usual  form,  sometimes  a  double  or  triple  invagina- 
tion may  occur,  or  an  incomplete  lateral  invagination,  the  reverse  of  a 
diverticulum.  The  mesentery  participates  in  the  invagination  and 
becomes  compressed  and  wedged  in  the  sheath.  The  serous  surfaces 
may  become  adherent,  so  that  the  invagination  cannot  be  disengaged. 
There  are  various  types  of  intussusception  which  may  occur  in  every 
portion  of  the  bowel. 

1.  The  Ileocecal  Form. — In  this  type  the  ileocecal  valve  forms  the  apex 
of  the  intussusception,  the  ileum  the  internal  cylinder,  and  the  colon  the 
sheath;  this  often  forms  a  very  long  intussusception,  so  that  the  valve 
may  even  protrude  at  the  anus. 

2.  The  Ileocolic  Form. — The  lowest  part  of  the  ileum  forms  the  apex 


868  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

and  protrudes  into  the  cecum.  If  the  cylinders  become  adherent,  then 
the  ileocecal  valve  and  cecum  may  become  inverted. 

3.  Ileaca-ileocolic  Form. — There  is  first  an  ileac  invagination  which 
may  force  the  intussuscepted  part  into  the  colon. 

There  may  also  be  intussusception  of  the  ileum,  jejunum  and  ileum, 
jejunum,  duodenum  and  jejunum,  duodenum,  colon,  colon  and  rectum, 
and,  rarely,  of  the  rectum. 

The  ileocecal  form  seems  to  predominate,  and  is  especially  frequent 
in  children. 

The  ileocolic  is  also  quite  frequent,  and  these  two  types  give  the  longest 
intusussceptions. 

In  adults  the  ileac  and  ileocecal  forms  occur  with  about  equal  frequency 
and  in  the  colon  it  is  quite  frequent. 

Intussuception  of  the  vermiform  appendix  into  the  cecum  has  been 
reported,  and  also  of  the  ileum  into  the  open  Meckel's  diverticulum,  when 
this  is  patent  at  the  umbilicus,  and  also  by  the  gut,  grasping  it,  or  by 
traction. 

The  mesentery  exerts  traction  on  the  intussusception  and  the  bowel 
curves  so  that  the  concavity  points  toward  the  mesenteric  attachment. 
This  may  cause  a  kinking,  which  further  closes  the  intestinal  lumen. 
Circulatory  changes  take  place  in  the  intussusception,  edema,  swelling, 
etc.,  and  in  severe  cases  strangulation  and  gangrene.  The  intussusception 
may  slough  ofif.  Peritonitis  is  first  noted  on  the  second  or  third  day;  it 
may  be  local  or  become  general. 

Mechanism  of  Intussusception. — The  probable  reason  of  intussuscep- 
tion being  so  frequent  in  young  children  is  that  during  the  early  months 
of  the  infant's  life  there  is  a  rapidly  increasing  disproportion  between  the 
transverse  diameters  of  the  large  and  small  intestines,  the  large  intestine 
increasing  very  rapidly  in  diameter,  so  that  the  ileum  can  readily  prolapse. 
For  the  production  of  invagination  there  is  probably  a  local  spasm  of  a 
portion  of  the  intestines,  and  the  normal  gut  below  is  pulled  upward  by 
its  longitudinal  fibers  over  the  contracted  piece  of  bowel,  and  the  irrita- 
tion caused  by  the  invaginated  part  then  causes  spasmodic  contraction 
of  the  gut  above,  which  carries  the  incarceration  further  downward. 

Numerous  experiments  have  been  carried  out  for  a  study  of  the 
mechanism.  None  of  these  seem  to  show  that  primary  paralysis  is  a 
factor,  but  that  the  condition  is  rather  of  a  spasmodic  type. 

Paralysis  of  a  limited  part  of  the  bowel  may,  I  believe,  be  a  factor  in 
some  cases. 

Frequency. — Weiss  finds  that  out  of  321  cases,  intussusception  occurs: 

Per  cent.  Per  cent.  Per  cent.  Per  cent. 

In  the  newborn  and  sucklings.   Iliac,  24      Ileocecal,  42  Ileocolic,  10  Colic,  24 

Childhood  to  puberty Iliac,  23      Ileocecal,  43  Ileocolic,  14  Colic,  26 

Adult Iliac,  29. 5  Ileocecal,  34. 5  Ileocolic,  4.5  Colic,  27 

Meckel's  diverticulum  (adult)...  4.5 

177  in  first  year;  85,  two  to  fourteen  years;  59,  later  age. 

The  agonal  type  of  intussucseption  occurs  just  before  death,  is  of  no 
importance,  and  is  often  multiple.  Of  Leichtenstern's  cases,  131  out  of 
543  occurred  in  the  first  year,  80  of  them  at  four  to  six  months. 


INTESTINAL   OBSTRUCTION — ACUTE   AND    CHRONIC  869 

Age. — Most  frequent  in  infancy  and  early  childhood,  up  to  the  fifth  year. 

Causes. — Diarrhea,  intestinal  polypi,  carcinoma  and  stricture,  inges- 
tion of  irritating  food,  contusion  of  the  abdomen,  shaking  the  body,  and 
acute  and  chronic  diseases  have  been  given  as  factors. 

Benign  tumors  when  present,  such  as  accessory  pancreas,  fibroma, 
myoma,  especially  the  polypoid  form,  are  generally  at  the  apex  of  the 
intussusception,  and  most  frequently  occur  in  the  ileum.  They  may  set 
up  peristalsis,  and  constriction  and  invagination  so  result. 

It  is  rare  with  carcinoma  or  stenosis,  and  it  may  occur  when  the  tumor 
is  pedunculated.     Often  the  cause  is  not  discoverable. 

Symptoms. — In  the  acute  cases  the  attack  is  characterized  by  its  sud- 
denness. There  may  be  preliminary  intestinal  disturbances,  such  as 
diarrhea  or  colicky  pains.  Often  they  appear  while  the  patient  is  quiet, 
asleep  or  nursing.  I  shall  refer  to  the  acute  cases  only  in  this  chapter. 
The  iliac  and  ileocecal  forms  are  the  most  acute.  The  colic  and  rectal 
form  are  more  gradual. 

Fain. — There  is  first  pain  of  a  violent  colicky  character,  at  times  aris- 
ing at  a  definite  point.  It  may  be  very  severe  and  overwhelm  the  patient, 
and  in  children  may  cause  convulsions,  or  they  may  scream  and  groan. 
It  is  continuous  at  first,  later  may  intermit,  though  at  times  it  may  be 
continuous  throughout.  In  some  cases  the  pain  is  in  the  right  iliac  region 
or  occasionally  at  the  umbilicus,  and  at  times  local  tenderness  is  present. 
Spasms  and  contraction  with  rigidity  of  loops  of  intestines  sometimes  occur 
in  acute  cases,  but  more  usually  in  the  chronic.  Vomiting  is  constant 
and  early  in  children,  is  not  constant  in  adults,  and  hence  is  a  less  impor- 
tant symptom  in  them. 

The  vomiting  depends  on  the  position  of  the  intussusception;  the 
lower  down  it  is,  the  less  likely  the  vomiting  at  the  outset;  peritonitis 
brings  it  on. 

Feculent  movements  may  occur  at  first;  later,  diarrhea  with  blood  and 
mucus,  and  tenesmus  if  the  invagination  is  low  down.  In  some  cases 
this  is  quite  marked ;  Jtemorrhages  from  the  bowels  ensue,  even  if  the  invag- 
ination is  high  up. 

Fecal  vomiting  is  rare.  Vomitus  usually  contains  gastric  contents, 
mucus,  and  bile,  and  only  occurs  in  one-fourth  of  the  cases  in  adults. 
The  higher  up  the  invagination,  the  sooner  it  appears.  Meteorism  of  a 
great  degree  is  exceptionally  present;  sometimes  the  abdomen  is  even  re- 
tracted.    It  is  dependent  on  the  degree  of  constriction. 

Tumor. — A  palpable  tumor  can  at  times  be  appreciated  in  about  one- 
half  the  cases.  It  varies  in  size,  may  seem  shorter  to  the  touch  than  it 
really  is,  or  it  may  impart  the  feel  of  a  double  swelling;  it  is  usually  of  a 
cylindric  or  sausage  shape,  elongated,  and  curved.  Its  consistency  may 
vary  at  different  times  and  it  can  be  slightly  compressed.  It  may  feel 
hard  and  then  suddenly  soft,  or  even  vanish.  The  changes  in  consistency 
and  resistance  are  due  to  the  spasmodic  contraction  in  the  intestinal  wall 
During  contraction  it  may  be  tender. 

Situation. — Most  frequently  the  tumor  is  located  in  the  region  of  the 
sigmoid;  then  at  the  anus  or  rectum,  then  at  the  cecum,  descending  trans- 
verse or  ascending  colon. 


870  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

The  position  of  the  tumor  may  be  permanent  if  there  are  any  adhe- 
sions, or  it  may  change  if  the  intussusception  increases. 
Prolapse  of  the  sweUing  through  the  anus  often  occurs. 
Duration. — Especially  in  children  severe  symptoms  of  collapse  may 
take  place  within  two  to  three  days,  and  if  vomiting  persists,  it  may  be 
feculent. 

About  80  per  cent,  of  young  subjects  die;  subacute  cases  run  two  to 
four  weeks  and  spontaneous  cures  occur  in  this  type. 

Death  from  collapse,  gangrene,  and  peritonitis  may  occur  during  the 
first  week  in  infants,  or  in  two  to  three  weeks  in  adults.  Sepsis  and  phlebi- 
tis may  be  associated. 

Diagnosis. — Acute  commencement,  vomiting  constant  in  children, 
but  not  so  in  adults;  at  times  tenesmus,  the  presence  of  bloody  stools;  then 

retention  of  feces  and  flatus,  distention 
of  tJte  abdomen  usually  slight;  and  last 
the  appearance  of  a  tumor  are  diag- 
nostic of  intussusception. 

Intussusception  of  the  Appendix. — 
Moschowitz,^  reports  a  case  of  intus- 
susception of  the  appendix  (Fig.  361), 
and  collects  24  additional  cases.  In 
the  pure  uncomplicated  cases,  with- 

_.       ^       ^  ,  ,.        J.  ,,  out  invagination  of  the  ileum  into  the 

Fig.  361. — Intussusception  of  the  ap-  1       i  •  .  1, 

pendix  vermiformis  (Cantlie).  cecum,    the   history   usually  covers  a 

considerable  period  from  a  few  weeks 

to  even  several  months.     The  oldest  patient  was  forty-two  years  old, 

the  youngest  two,  and  the  general  average  was  five  years  of  age. 

Symptoms. — The  pain  is  usually  intense,  cramp-like,  and  localized 
around  the  umbilicus.  It  occurs  in  paroxysms,  during  which  period 
the  patient  suffers  severely.  The  distinguishing  feature  of  the  pain 
is  its  remitting  character.  During  the  period  of  remission  the  patient 
may  apparently  feel  perfectly  well.  Attacks  of  pain  with  remission 
alternate  and  there  may  be  from  one  to  two  to  many  attacks  a  day. 
The  duration  of  the  disease  varies  from  a  few  weeks  to  several  months. 
There  is  rigidity  of  the  abdominal  muscles  but  examination  with  the 
patient  in  a  hot  bath  or  under  an  anesthetic  enables  one  to  determine  a 
swelling  about  the  size  of  an  egg  in  the  right  iliac  fossa.  It  differs  from 
the  sausage-shaped  swelling  of  an  ileocolic  intussusception.  The  bowels 
may  move  spontaneously  or  with  cathartics.  Blood  in  gross  or  minute 
quantites  (by  chemical  test)  is  present  in  the  stool  during  the  cramp-like 
attacks.  The  remissions  and  chronicity  differentiate  it  from  acute  in- 
vagination involving  the  entire  gut. 

Obturation  of  the  intestines  signifies  the  occlusion  of  the  bowels 
by  a  foreign  body  situated  therein;  among  such  are  gall-stones,  entero- 
liths, foreign  bodies  which  have  been  swallowed  or,  rarely,  inserted  into 
the  rectum,  lumbricoid  worms,  and  masses  of  fecal  matter. 

Gall-stones,  in  exceptional  cases  if  very  large,  may  cause  an  acute 
intestinal  obstruction.  They  probably  have  ulcerated  through  into 
^  N.  Y".  Med.  Rec,  Dec.  17,  1910. 


INTESTINAL   OBSTRUCTION — ACUTE   AND    CHRONIC  87I 

the  bowel  from  the  gall-bladder.  They  may  become  impacted  in  the 
duodenum,  jejunum,  or  at  the  ileocecal  valve. 

Cases  of  this  last  type  are  more  frequent  in  women  than  in  men.  In 
many  there  is  a  previous  history  pointing  to  cholelithiasis.  The  symp- 
toms are  pain,  violent  vomiting  (generally  bilious),  which  frequently 
becomes  feculent,  constipation,  which  is  not  always  absolute,  meteorism, 
often  not  pronounced,  and  collapse.  In  some  cases  a  hard  resistant  swell- 
ing may  be  felt.  In  others  there  will  be  some  flatus  from  the  rectum. 
Milder  symptoms  of  occlusion  may  occur,  evidently  when  the  lumen  of 
the  bowel  is  not  completely  shut  ofif.  The  patient  in  this  class  of  cases 
would  suffer  from  attacks  of  colicky  pain,  vomiting,  and  constipation, 
but  no  collapse.  These  cases  may  also  have  perforative  peritonitis,  and 
often  die  on  the  fifth  to  tenth  day  unless  operated  on.  At  times  the  stone 
may  move  onward  and  escape,  with  recovery  of  the  patient. 

Occasionally  there  will  be  some  diarrhea  with  blood  during  the  onward 
movement  of  the  calculus,  the  result  of  traumatism  to  the  mucosa. 

Enteroliths. — An  intestinal  calculus  rarely  causes  acute  obstruction 
unless  it  has  been  dislodged  from  an  intestinal  diverticulum,  and  suddenly 
occludes  the  bowel.  It  generally  produces  the  symptoms  of  chronic  ob- 
struction or  digestive  disturbances  and  obstinate  constipation. 

Calculi  ordinarily  consist  of  carbonates  or  phosphates  with  a  foreign 
body  as  a  nucleus;  or  as  a  result  of  the  prolonged  use  of  drugs,  such  as 
chalk,  bismuth,  magnesia  or  salol,  or  some  indigestible  material,  such  as 
oat-stones  from  oatmeal,  etc.,  in  which  inorganic  salts  are  deposited. 
They  frequently  develop  in  the  large  intestine. 

Foreign  Bodies. — These  are  accidentally  or  intentionally  swallowed. 
This  is  especially  apt  to  occur  with  children  or  with  insane  or  hysteric 
persons.  Occlusion  has  also  been  produced  by  the  insertion  of  a  foreign 
body  into  the  rectum.  Among  such  substances  are  knives,  spoons,  forks, 
keys,  marbles,  stones,  false  teeth,  fruit  stones,  neckties,  hair  or  beads,  pins 
and  needles;  in  fact,  all  varieties  of  objects.  In  some  cases  the  symptoms 
may  first  be  chronic,  when  suddenly  acute  occlusion  will  occur;  in  others 
it  is  acute  from  its  incipiency.  Murphy's  button  has  caused  occlusion, 
also  a  large  mass  of  tapeworms  or  round  worms.  Pedunculated  tumors 
of  the  intestinal  wall,  such  as  polypi,  fibroma,  and  myoma,  may  produce  it. 

Many  of  these  objects  can  be  readily  recognized  by  means  of  the  :\;-rays 
and  the  fluoroscope,  or  by  a  Rontgen  picture. 

Fecal  masses  may  completely  occlude  the  intestines  as  a  result  of  habit- 
ual constipation.  The  symptoms  are  usually  subacute  or  chronic  at  first, 
and  finally  become  acute  from  complete  occlusion. 

Dynamic  Ileus  (Intestinal  Paresis). — Acute  obstruction  produced  by 
paralysis  of  the  bowels  is  called  paralytic  or  dynamic  ileus.  Among  the 
various  causes  are  hydrocele,  contusion  or  inflammation  of  the  testicles, 
etc.,  which  may  cause  a  reflex  paresis;  paracentesis  of  ascites;  trauma  over 
the  abdomen;  after  laparotomy  from  manipulation  of  the  viscera  or  follow- 
ing removal  of  a  large  tumor,  or  after  Cesarean  section;  other  operations 
from  the  effect  of  the  anesthetic;  damage  to  the  intestines,  as  from  hernia 
after  relief  of  the  strangulation;  local  or  general  peritonitis;  renal  or  biliary 
colic  may  cause  reflex  obstruction,  possibly  due  to  spasm  or  paresis;  over- 


872  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

distention  of  the  intestines  from  gas  or  feces;  various  toxemias,  as  from 
typhoid  or  pneumonia  or  from  any  acute  infection,  also  sepsis,  as  from 
appendicitis,  and  as  a  concomitant  of  shock  or  uremia. 

Congenital  Causes. — Congenital  occlusion  of  the  rectum  or  colon  pro- 
duces acute  obstruction. 

Acute  Obstruction  Engrafted  on  Chronic  Obstruction.— Chronic  stenosis 
with  chronic  constipation  may  suddenly  produce  an  acute  obstruction. 

Pathology  of  Acute  Obstruction. — In  acute  obstruction  the  pathologic 
findings  differ  somewhat,  according  to  the  various  types  and  factors. 
There  has  been  an  unfortunate  tendency  to  confuse  the  findings  in  acute 
and  chronic  obstruction.  If  we  have  an  acute  condition  engrafted  on  a 
chronic  obstruction,  we  may  then  find  above  the  point  of  obstruction  dila- 
tation and  hypertrophy  of  the  intestines,  catarrh,  and  ulcerations. 

In  true  acute  occlusion  the  process  is  too  rapid  for  these  changes,  but 
the  following  occur:  the  intestines  below  the  occlusion  are  empty  and  con- 
tracted; above  it  the  intestines  are  markedly  dilated  and  distended  and  the 
walls  are  thinner.  If  a  loop  is  involved,  the  walls  are  thick  and  congested 
(but  not  hypertrophied).  The  coils  above  the  obstruction  are  distended, 
filled  with  gas  and  ill-smelling  contents.  If  the  small  intestine  is  occluded 
the  distention  will  involve  the  gastrointestinal  tract  above  the  occlusion; 
if  the  large  intestine  is  occluded  the  colon  will  be  distended  first;  later 
regurgitation  through  the  ileocecal  valve  occurs  and  universal  distention. 

In  a  loop  which  is  strangulated,  there  is  local  meteorism,  and  it  may  be 
markedly  distended;  there  are  congestion,  edema,  hemorrhage,  a  dark  red 
color  of  the  gut  and  gangrene,  with  general  peritonitis  and  bloody  fluid 
in  the  cavity;  or  a  single  perforation  from  ulceration  or  gangrene  may 
occur  (the  distention  ulcer  with  perforation  "  Dehnungsgeschwiir,"  de- 
scribed by  Kocher);  and  rarely,  if  the  case  be  prolonged,  a  local  abscess  or 
local  peritonitis. 

General  Symptoms  of  Acute  Obstruction. — As  a  rule  these  begin  very 
acutely,  though  rarely  there  is  a  previous  history  of  diarrhea  or  constipa- 
tion, improper  food,  a  laxative,  traumatism,  or  of  violent  exertion. 

There  are  at  first  violent  abdominal  pains,  colicky  in  type,  local  or  dif- 
fuse. The  pain  is  continuous,  though  sometimes  it  may  remit.  Nausea, 
hiccough,  and  vomiting  first  of  the  gastric  contents,  later  bilious,  and, 
finally,  feculent  vomiting  rapidly  follow.  Meteorism  quickly  appears; 
there  are  absolute  constipation  and  no  passage  of  flatus.  Tympanites 
increases,  a  great  increase  of  intra-abdominal  pressure  is  present,  and  the 
muscles  become  tense  and  rigid  and  the  entire  abdomen  tympanitic;  res- 
piration is  markedly  interfered  with,  the  breathing  is  rapid  and  shallow, 
pulse  rapid  and  feeble,  extremities  cold,  cold  sweat,  face  pale,  eyes  sunken, 
and  extreme  thirst;  total  collapse  and  the  patient  rapidly  succumbs. 
General  peritonitis  occurs. 

Only  a  brief  analysis  will  be  made  of  these  symptoms,  as  they  have 
been  thoroughly  described  under  the  respective  causes  of  acute  obstruc- 
tion. Pain  is  the  most  constant  symptom  and  it  never  remits  completely. 
As  a  rule,  it  is  more  acute  in  obstruction  of  the  small  intestine;  the  initial 
pain  is  probably  due  to  irritation  of  the  intestines  and  peritoneum,  later 
to  spasmodic  intestinal  contraction,  and  finally  to  peritonitis.     In  the 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  873 

last  Stage  pain  may  cease  as  a  result  of  the  terminal  fatal  intestinal  paresis. 
External  pressure,  as  a  rule,  increases  the  pain. 

Active  and  visible  peristaltic  movetnents  and  tetanic  stiffening  of  the 
bowel  are  exceptionally  seen  in  acute  occlusion,  when  the  intestines  were 
previously  healthy  and  unobstructed;  and  if  they  are  visible,  are  never 
as  marked  as  in  cases  of  acute  obstruction  supervening  on  a  chronic  stenosis 
of  the  intestine.  This  is  an  important  point  to  remember.  The  visible 
peristaltic  movements  if  present,  in  connection  with  the  other  symptoms 
are  an  aid  to  diagnosis. 

Vomiting  is  nearly  always  present.  At  first  it  is  probably  due  to  reflex 
irritation  of  the  nervous  system;  later  it  has  been  ascribed  to  antiperistal- 
sis;  or  to  mechanical  causes,  as  explained  by  Haguenot,  who  states  that 
fluid  contents  accumulate  above  the  obstruction;  and  from  gas  pressure 
and  contraction  of  the  abdominal  muscles  the  contents  are  forced  into  the 
areas  of  less  resistance  and  thus  reach  the  stomach,  where  they  cause 
vomiting. 

Feculent  vomiting  often  occurs  when  the  obstruction  is  in  the  small 
intestine,  due  to  putrefactive  processes  therein. 

Constipation  is  usually  marked;  though  rarely  there  is  diarrhea  with 
blood,  as  in  intussusception. 

Absence  of  flatus  is  quite  significant. 

Meteor  ism. — This  may  first  be  circumscribed  (local),  there  being 
tympanites  and  protrusion  of  the  intestines  for  a  short  distance  above  the 
point  of  obstruction;  thus,  a  protrusion  of  the  right  side  would  first  be 
noted  if  an  obstruction  occurs  at  the  hepatic  flexure.  Later  the  meteorism 
becomes  general  and  the  abdomen  barrel  shaped. 

Collapse. — This  is  marked,  especially  so  if  there  is  strangulation,  and 
it  is  more  rapid  if  the  small  intestine  is  involved. 

Thirst  and  dryness  of  the  tongue  are  present,  being  due  to  vomiting, 
sweating,  and  increased  intestinal  secretion,  which  diminish  the  fluidity 
of  the  blood. 

Coma,  delirium,  and  fever  rarely  occur,  unless  a  general  peritonitis. 

Diagnosis  of  Acute  Intestinal  Obstruction. — Having  described  the 
symptoms  of  acute  obstruction,  a  careful  study  of  the  physical  signs 
and  the  methods  of  physical  examination  are  necessary  to  complete  the 
diagnosis. 

Investigation  of  the  type  and  degree  of  meteorism  (tympanites),  both 
by  inspection  and  percussion,  is  of  great  importance.  At  this  point  I 
again  desire  to  call  to  my  reader's  attention  that  acute  dilatation  of  the 
stomach  presents  many  symptoms  of  ileus  and  may  obscure  the  diagnosis. 
The  pain  of  acute  ectasia  is  not  as  severe  and  continuous  as  with  acute 
intestinal  obstruction,  in  that  it  is  immediately  relieved  by  lavage.  The 
stomach  may  occupy  the  entire  abdominal  cavity,  though  usually  it  fills 
the  left  half  and  lower  part  of  the  abdomen.  The  vomiting  of  acute 
ectasy  is  also  pecuUar,  in  that  it  is  very  profuse,  incessant,  and  in  large 
amount,  and  comes  up  in  gulps  without  straining.  It  is  usually  watery 
and  greenish  in  hue,  though  it  may  be  brownish  or  black.  If  the  stomach 
alone  is  involved,  distention  will  disappear  after  lavage.  Temperature  is 
normal  or  subnormal.     Vomiting  is  nonstercoral. 

Inspection. — If  there  be  occlusion  of  the  jejunum  or  duodenum,  unless 


874  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

the  Stomach  also  be  greatly  dilated,  the  upper  part  of  the  abdomen  is 
protruded  slightly. 

Occlusion  at  the  cecum  or  lower  ileum  gives  the  so-called  "ladder" 
pattern,  the  coils  lying  one  above  another  either  obliquely  or  transversely 
in  the  abdomen,  and  the  distention  is  more  central. 

In  stenosis  of  the  sigmoid  flexure^  the  upper  and  lateral  aspects  of  the 
abdomen  are  usually  distended,  and  we  have  so-called  flank  meteorism. 

When  the  distention  is  limited  to  a  section  of  the  colon,  flank  meteorism 
may  be  unilateral ;  thus  the  right  iliac  region  is  intensely  tympanitic  if  the  oc- 
clusion involves  the  hepatic  flexure.  If  the  small  intestine  alone  be  included, 
the  distended  loops  are  seen  in  the  center  and  flank  meteorism  is  absent. 

With  volvulus  the  left  lower  portion  of  the  abdomen  protrudes;  or 
an  S-shaped  protrusion  of  the  abdomen,  most  prominent  at  the  upper  left 
and  lower  right  quadrants,  occurs. 

We  must  remember  that  local  meteorism  occurs  only  early,  and  later 
general  tympanites  ensues,  so  that  we  may  not  see  the  case  early  enough 
to  avail  ourselves  of  these  data. 

Peristaltic  waves,  if  present,  aid  to  locate  the  obstruction. 

Palpation. — In  some  cases  palpation  reveals  a  circumscribed  area 
which  is  tender^  on  pressure,  and  may  aid  in  localizing  the  obstruction. 
In  others  a  tumor  is  palpable,  especially  with  intussusception,  occlusion 
by  tumors,  or  fecal  impaction. 

Palpation  of  the  hernial  openings  is  necessary.  Digital  examination 
of  the  rectum  and  vagina  are  most  important.  We  may  feel  a  stricture 
or  intussusception  in  the  rectum  and  bloody  fluid  may  escape.  I  depre- 
cate the  method  of  inserting  the  hand  in  the  rectum. 

Percussion. — Local  meteorism  gives  a  deep  and  loud  note,  which  is  not 
truly  tympanitic,  but  often  of  a  metallic  ring,  and  helps  locate  the  obstruc- 
tion. Exceptionally,  dull  percussion  may  be  heard  over  the  swelling,  due 
to  edema  of  the  intestinal  walls  or  to  accumulation  of  fecal  contents  or 
blood  admixture. 

In  normal  subjects  the  percussion  note  in  the  upper  lumbar  region 
behind,  is  high,  flat,  and  dull.  It  is  loud  and  deep  in  stenosis  of  the  large 
intestine.  When  the  obstruction  is  in  the  sigmoid,  the  loud  and  deep  note 
is  found  on  both  sides,  and  when  in  the  splenic  flexure  or  transverse  colon, 
then  only  in  the  upper  lumbar  region  of  the  right  side. 

If  there  is  general  tympanites  and  no  change  of  percussion  is  noted  for 
a  long  time  over  any  one  region  of  the  abdomen,  there  is  probably  intes- 
tinal paresis.  General  tympanites,  with  absence  or  diminution  of  liver 
does  not  always  mean  perforation  of  the  bowel,  though  it  frequently 
does  so.     One  can  often  determine  peritoneal  exudation  by  percussion. 

Auscultation. — Splashing  and  gurgling  noises  often  demonstrate  that 
peristalsis  is  marked.  Succussion  sounds  and  fluctuation  on  palpation 
are  frequently  found  in  the  intestines  above  the  point  of  stenosis.  Ex- 
amination of  the  vomited  matter  will  show  whether  fecal  material  is  pres- 
ent. Urine  is  scanty  and  albuminous,  and  often  shows  indican  and  gives 
Rosenbach's  reaction,  especially  in  obstruction  of  the  small  intestine. 

1  Ultimately  complete  distention  with  barrel-shaped  abdomen  may  occur. 
-  Muscular  rigidity  shows  peritonitis. 


INTESTINAL   OBSTRUCTION — ACUTE    AND    CHRONIC  875 

Suppression  of  urine  occurs  in  this  condition.  The  writer  opposes  the 
use  of  -T-rays  for  diagnosis  in  acute  cases. 

Differential  Diagnosis  Between  Obstruction  of  the  Small  and  Large 
Intestine. — Obstruction  of  Small  Intestine — Pain,  vomiting,  and  collapse 
are  more  acute  and  appear  early.  Early  feculent  vomiting.  Indicanuria 
early,  on  second  or  third  day.  Anuria  early,  early  me  tear  ism,  and  often  is 
high  up.  Absence  of  early  indicanuria  (excluding  peritonitis  and  intes- 
tinal inflammation)  tends  to  show  obstruction  is  not  in  the  small  intestine. 

Vomiting  in  duodenal  obstruction  is  rarely  feculent,  but  is  so  if  the 
obstruction  is  lower  down. 

Obstruction  of  Large  Intestine. — If  the  disease  is  chronic  or  runs  a  long 
course,  absence  of  indican  shows  lesion  is  present  in  the  large  intestine; 
its  presence,  however,  tells  nothing,  as  it  may  appear  late. 

General  symptoms  are  usually  less  violent,  though  they  are  violent  in 
volvulus.  Fecal  vomiting  occurs  later.  Meteroism  is  lower  down  in  the 
early  stage  of  acute  obstruction. 

Tenesmus  and  blood  in  the  stool  suggest  an  obstruction  low  down. 
Brinton's  method  by  the  injection  of  water  is  sometimes  of  service.  If 
not  more  than  i  quart  can  be  injected,  the  obstruction  is  probably  low 
down;  if  2  quarts,  it  is  probably  above  the  sigmoid,  and  if  4  quarts,  then 
in  the  commencement  of  the  colon  or  higher  up. 

Inflating  the  bowel  with  CO2  by  Rose's  bottle  or  by  air  will  fill  the 
large  intestine  up  to  the  obstruction.  This  method  is  of  no  service  if  there 
is  very  marked  distention,  and  lavage  should  be  first  performed  to  reduce 
it.  • 

Differential  Diagnosis  between  the  Different  Forms  of  Acute  Obstruc- 
tion.— This  is  often  difl&cult.  In  some  cases  it  is  possible,  but  in  others 
we  can  only  conjecture  the  probable  type. 

Acute  strangulation  in  hernias,  omental  slits,  or  by  bands  constitutes 
about  34  per  cent,  of  cases.  This  is  more  frequent  in  males  between 
twenty  and  forty  years.  In  90  per  cent,  the  small  intestine  is  the  seat 
of  trouble,  mostly  in  the  ileum  and  lower  abdomen  or  right  iliac  fossa. 
The  symptoms  are  sudden  and  acute.  There  may  have  been  a  previous 
history  of  peritonitis,  hernia,  or  injury.  Pains  are  severe,  vomiting  begins 
early  and  soon  becomes  feculent,  absolute  constipation  is  present  and  no 
passage  of  flatus.  Tenesmus  absent.  Collapse  is  early  and  marked. 
Urine  is  scanty  and  meteorism  slight.  Attack  is  of  fulminating  type. 
Physical  examination  often  gives  no  definite  data. 

Volvidus. — This  most  frequently  involves  the  sigmoid.  History  fre- 
quently of  chronic  constipation,  is  more  common  in  males  and  in  those 
over  forty  years  of  age,  from  forty  to  sixty,  though  Fitz's  statistics  show 
frequency  from  thirty  to  forty  years  of  age.  If  volvulus  is  of  the  small 
intestine,  it  cannot  be  differentiated  from  incarceration.  Pain  is  sudden 
and  violent,  it  may  remit,  but  never  intermits.  Vomiting  is  quite  com- 
mon, but  may  be  absent  at  first  in  volvulus  of  the  sigmoid,  and  in  the 
latter  case  fecal  vomiting  may  not  be  present.  It  occurs  in  some  cases, 
but  is  not  as  frequent  as  in  internal  strangulation;  in  fact,  it  is  rather  rare. 
Meteorism  occurs  early  and  is  at  first  local  in  the  lower  left  quadrant,  or  as 
an  S-shaped  protrusion.  General  meteorism  rapidly  occurs,  and  thus  is  an 


876  DISEASES    or    THE    STOMACH    AND    INTESTINES 

aid  to  diagnosis.  The  sigmoid  can  occasionally  be  felt  as  a  tumor.  Con- 
stipation and  absence  of  flatus  are  usually  complete;  occasionally  there  is 
a  little  blood  in  the  stool  and  only  a  moderate  amount  of  water  can  be 
injected  into  the  rectum.     Symptoms  are  acute  and  collapse  is  marked. 

Intussusception. — Most  frequently  in  infancy  and  early  childhood. 
Onset  is  sudden.  Pains  appear  early,  are  colicky  in  character;  in  children, 
may  cause  them  to  scream  or  have  convulsions;  pains  are  paroxysmal. 
Vomiting  occurs  early  and  constantly  in  children;  a  less  important  symptom 
in  adults. 

Invaginated  coil  can  be  appreciated  or  a  tumor  in  about  one-half  the 
cases.     Occasionally  the  swelling  may  prolapse  through  the  anus. 

Tenesmus  and  evacuation  of  blood  occur,  then  constipation  and  reten- 
tion of  flatus.     Fecal  vomiting  rare,  unless  case  is  prolonged;  collapse  is 


Fig.  362. — Section  of  obstructed  intestine  after  opening  into  lumen,  showing 

worms  (Whelan). 

early  in  children  (in  two  to  three  days),  but  not  as  early  as  in  strangulation; 
collapse  is  slower  in  adults. 

Obstruction  by  Gall-stones,  Enteroliths,  and  Foreign  Bodies. — Occlusion 
from  gall-stones  occurs  chiefly  in  older  women.  There  is  at  times  a  prev- 
ious history  of  gall-stones,  jaundice,  and  liver  enlargement  or  tenderness, 
which  aids  our  diagnosis.  The  obstruction  usually  occurs  in  the  small 
intestine.  The  general  symptoms  are  often  not  so  severe  as  in  other  t>^es, 
there  being  some  flatus  passed  at  times  and  in  some  cases  slight  diarrhea 
with  blood.  If  obstruction  of  the  ileum,  feculent  vomiting  is  more  marked. 
Meteorism  is  not  so  marked  and  collapse  not  so  great.  Occasionally  the 
stone  can  be  palpated. 

Enteroliths. — Their  recognition  is  quite  difl&cult  unless  small  fragments 
have  been  voided.     They  develop  most  frequently  in  the  large  intestine. 


INTESTINAL   OBSTRUCTION ACUTE   AND    CHRONIC  877 

Symptoms  of  chronic  obstruction  or  digestive  disturbances  and  obstinate 
constipation  are  more  frequent.     Acute  symptoms  are  more  rare. 

Foreign  Bodies. — The  previous  history  and  use  of  the  :c-rays  will  de- 
termine these.  Obstruction  from  accumulation  of  fruit  pits  will  generally 
be  suspected  by  reason  of  the  appearance  of  some  of  them  in  the  stool. 

Ascaris  Lumbricoides. — An  interesting  case,  demonstrating  that  round 
worms  may  be  the  cause  of  intestinal  obstruction  in  a  young  child,  has 
been  reported  by  Charles  Whelan.^  The  patient,  male,  aged  five  and  a 
half  years,  about  April  i,  1910,  became  peevish,  restless,  complained  of 
loss  of  appetite  and  frequently  of  stomachache.  The  child  became  ob- 
stinately constipated.  No  worms  were  noted  in  the  stools  by  the  mother. 
On  Aug.  2d,  the  child  awoke  about  midnight  crying  with  pain,  and  soon 
afterward  began  to  vomit.  This  continued  for  two  days,  the  abdomen 
becoming  more  and  more  distended.  The  vomiting  increased  in  fre- 
quency and  the  pulse  became  extremely  rapid,  with  evidences  of  shock. 
Several  convulsions  occurred,  the  child  dying  during  a  convulsive  seizure. 
The  autopsy  showed  an  impacted  mass  obstructing  the  lower  jejunum  for 
about  61-2  inches.  The  first  2  inches  were  completely  occluded  by  a 
bunch  of  round  worms,  then  there  was  a  "kink"  or  constriction.  Two 
worms  lay  side  by  side  in  the  direction  of  the  long  axis  of  the  bowel,  passing 
through  the  constricted  portion.  The  lower  2  inches  of  the  jejunum 
were  also  completely  occluded  by  the  worms  (Fig.  362).  The  condition 
was  evidently  an  acute  engrafted  on  a  chronic  obstruction. 

Fecal  Accumulation. — This  rarely  gives  the  picture  of  acute  obstruc- 
tion unless  a  tumor  or  stricture  of  the  intestine  be  present,  when  accumula- 
tion may  suddenly  cause  complete  occlusion.  Rectal  examination  usually 
shows  hardened  scybalae,  and  palpation  demonstrates  a  hardened  mass  in 
the  colon  (descending,  sigmoid  or  cecum  especially).  If  the  mass  be  softer, 
it  will  impart  a  doughy  feel  on  pressure. 

Dynamic  Ileus. — Acute  gastroduodenal  dilatation  of  the  stomach  pre- 
sents symptoms  of  intestinal  obstruction,  and  commences  with  acute  pain, 
undoubtedly  due  to  stenosis  of  the  duodenum  by  pressure.  Under  Diag- 
nosis of  Acute  Obstruction  I  have  described  the  peculiar  type  of  vomiting 
in  acute  ectasy  and  also  the  position  of  the  stomach.  The  pain,  disten- 
tion, and  other  symptoms  are  relieved  by  frequent  lavage  and  by  the 
adoption  of  the  abdominal  position  (the  patient  lying  on  his  belly). 

Obstruction  of  the  bowel  from  a  paralytic  condition  involves,  as  a  rule, 
a  considerable  segment,  or  frequently  the  entire  tract.  After  reduction 
of  a  hernia  probably  only  a  small  segment  is  first  involved,  but  I  believe 
paralysis  of  a  considerable  segment,  and  in  many  cases  of  the  entire  bowel, 
finally  results.  The  acute  cramp-like  pains,  persistent  and  paroxysmal, 
are  absent  in  this  type  of  obstruction  (really  not  a  true  obstruction  at  all), 
which  always  occur  in  the  early  stages  of  other  types  of  obstruction. 
When  acute  spasmodic  pain  is  present  aftd  persistent,  I  always  feel  positive 
of  a  true  obstruction.  The  vomiting,  constipation,  collapse,  etc.,  may  be 
similar  to  obstructive  ileus.  There  may  be  sudden  pain  with  the  acute 
distention,  so  that  perforation  is  suspected,  but  after  lavage  and  enterocly- 
sis  the  pain  disappears,  and  muscular  rigidity  is  found  to  be  absent.  These 
*Jour.  Amer.  Med.  Assoc,  Oct.  22,  1910. 


878  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

features  exclude,  first,  ''obstructive  ileus,"  on  account  of  disappearance 
of  the  pain;  and  second,  "peritonitis."  In  the  early  stages  of  "dynamic 
ileus,"  distention,  interference  with  the  cardiorespiratory  functions,  and 
obstinate  constipation  precede  the  vomiting  and  severe  symptoms  as  a 
rule.  There  is  usually  more  of  a  sense  of  painful  discomfort  and  oppres- 
sion, except  in  the  cases  of  sudden  acute  distention. 

In  the  terminal  stages  of  true  obstruction,  paresis  of  the  bowel  may 
occur,  and  then  spasmodic  pain  disappears;  in  paresis  of  the  bowel  from 
peritonitis  there  is  the  general  pain  and  tenderness  from  the  peritonitis, 
but  not  the  acute  spasmodic  pain  peculiar  to  true  obstruction. 

In  true  dynamic  ileus,  therefore,  there  is  the  absence  of  that  acute 
persistent  spasmodic  pain  of  severe  type  which  is  present  in  all  cases  of 
true  obstruction,  and  absence  of  muscular  rigidity. 

Differential  Diagnosis  between  Intestinal  Obstruction  and  Other 
Diseases. — Acute  Peritonitis. — Generally  a  history  of  local  peritonitis, 
such  as  appendicitis  with  pain  localizing  in  the  right  iliac  fossa,  and  then 
sudden  cessation  of  the  cramp-like  pains,  followed  by  abdominal  tender- 
ness, muscular  rigidity,  great  distention,  and  frequently  a  rise  of  tem- 
perature. Leucocytosis  and  increase  in  polynuclears  are  present.  Vomit- 
ing generally  begins  later  and  feculent  vomiting  still  later,  etc. 

In  obstruction  the  character  of  pain  is  more  severe  and  persistent,  as 
a  rule,  and  often  in  the  umbilical  region  or  in  the  left  lower  quadrant; 
temperature  is  subnormal  at  the  start;  abdominal  tenderness  is  not  as 
marked;  feculent  vomiting  earlier;  often  local  meteorism  before  general 
tympanites.  General  pains  are  colicky  and  persistent  until  peritonitis 
and  paresis  set  in.  The  paralytic  form  of  ileus  may  often  occur  with 
infectious  diseases,  or  acute  appendicitis  with  peritonitis  (general),  also 
after  operation  or  inflammation  in  the  pelvis  or  genito-urinary  organs; 
and  the  knowledge  of  these  facts  aid  our  diagnosis.  We  must  remember 
that  in  hysteric  women  all  the  symptoms  of  ileus,  even  to  fecal  vomiting, 
may  occur  without  there  being  any  obstruction. 

With  biliary  and  renal  colic  there  may  be  a  reflex  paralytic  ileus,  but 
the  symptoms  of  these  conditions  aid  the  diagnosis. 

Lead-  and  arsenic-poisoning  have  sometimes  been  mistaken  for  ileus, 
but  again  we  have  the  history  and  other  symptoms,  especially  of  enteritis. 
Simple  intestinal  colic  soon  subsides  under  treatment.  Acute  pancreatitis 
and  enteritis  give  their  symptoms. 

There  is  tenderness  in  the  course  of  the  pancreas  if  this  is  involved, 
a  circumscribed  epigastric  swelling,  and  tender  spots  throughout  the 
abdomen  (Fitz) ;  tenderness  at  Robson's  point,  history  of  gall-stones  as  a 
rule,  jaundice,  hematemesis,  melena,  and  hemorrhages  from  all  the  mucus 
membranes,  subnormal  temperature,  constipation,  but  in  some  cases  it  is 
difficult  to  differentiate  acute  pancreatitis  from  obstruction.  The  former 
presents  the  aspects  of  an  epigastric  peritonitis.  Fat  necrosis  is  found  on 
operation. 

Course. — The  course  of  acute  obstruction  depends  upon  its  cause  and 
site.    The  higher  up  in  the  intestine,  the  more  acute  the  course,  as  a  rule. 

Volvulus  and  strangulation  are  very  acute.  The  patient  may  die  in 
collapse  within  a  few  hours,  or  the  course  may  be  prolonged  to  two  or 


INTESTINAL   OBSTRUCTION — ACUTE   AND    CHRONIC  879 

three  days  or  even  a  week.  Intussusception,  if  unoperated,  may  last 
several  weeks.  If  the  patient  survives  the  collapse,  and  the  patency  of 
the  gut  becomes  reestablished  (as  in  intussusception,  foreign  bodies,  or 
volvulus),  flatus  is  first  passed  and  then  later  a  fecal  movement,  and  the 
symptoms  gradually  abate.  The  invaginated  bowel  has  been  known  to 
slough  off  and  be  passed  in  the  stool.  From  changes  in  the  gut,  due  to 
ulcers,  adhesions,  etc.,  the  patient  may  subsequently  develop  symptoms 
of  chronic  obstruction. 

If  operation  is  not  performed,  the  patient  usually  dies  of  acute  shock 
or  peritonitis.  The  latter  may  be  due  to  perforation  or  to  direct  penetra- 
tion of  the  paralyzed  wall  of  the  gut  by  intestinal  bacteria.  It  is  further 
believed  that  toxemia  from  intestinal  bacteria  may  be  a  cause  of  death. 

In  some  there  may  be  a  circumscribed  peritonitis.  With  the  diffuse 
peritonitis  we  have  the  symptoms  already  described. 

Embolic  processes  may  develop  in  the  liver,  lungs,  and  other  organs. 
There  may  be  aspiration  pneumonia,  or  exceptionally,  local  abscess,  with 
perforation  of  the  abdominal  wall,  or  into  another  part  of  the  intestines 
or  into  other  viscera,  as  into  the  stomach,  bladder,  vagina,  or  uterus. 

Prognosis. — The  prognosis  of  acute  obstruction  is  very  serious. 
Some  observers  state  that  about  one-third  of  all  cases  recover,  however. 

Obstruction  caused  by  coprostasis,  gall-stones,  or  some  foreign  body 
give  the  best  prognosis.  Dynamic  ileus  with  modern  methods  of  treat- 
ment, I  believe,  is  next  in  regard  to  favorable  results,  then  intussusception, 
and  the  worst  cases  are  volvulus  and  strangulation.  The  earlier  the 
operation,  the  better  the  prognosis.  The  last  types  I  believe  fatal  nearly 
invariably,  unless  early  operation  is  carried  out. 

Treatment. — This  may  be  divided  into  medical  and  surgical,  and^ 
the  respective  indications  are  extremely  clear.  I  shall  first  briefly  classify 
these,  giving  the  treatment  in  tabulated  form. 

Cases  for  Medical  Treatment. — i.  Acute  obstruction  due  to  fecal  ac- 
cumulation. Acute  attacks  are  rare;  they  are,  rather,  subacute  or  acute 
engrafted  on  chronic: 

(a)  Lavage  is  indicated  to  relieve  tympanites,  if  present,  or  if  vomiting. 

(i)  Digital  examination  of  the  rectum  and  removal  of  scybalae  with 
the  fingers,  and  then  frequent  enemata  of  soapsuds,  olive  oil,  glycerin, 
or  6  ounces  (200  c.c.)  of  magnesium  sulphate  (saturated  solution)  in 
water,  i  pint  (500  c.c),  followed  by  recurrent  enteroclysis  with  normal 
saline  solution  at  110°  to  i2o°F.,  using  2  to  3  gallons  at  a  sitting,  about 
yito  x  pint  (250-500  c.c.)  being  kept  in  the  bowel.  For  the  first  twenty- 
four  to  forty-eight  hours  the  treatment  consists  in  the  simple  mechanical 
emptying  of  the  rectum  and  large  intestine.  The  enemata  should  contain 
about  I  to  2  quarts  (Hters),  in  which  is  olive  oil,  i  pint  (500  c.c),  alone 
or  with  glycerin,  4  ounces  (125  c.c).  It  is  well  to  give  the  enema  with 
the  patient  in  the  knee-chest  position,  the  buttocks  elevated  as  high  as 
possible.  In  two  recent  cases  the  writer  found  a  high  enema  containing 
olive  oil,  8  ounces  (250  c.c);  glycerin,'  4  ounces  (125  c.c);  castor  oil,  2 
ounces  (60  c.c);  and  several  grains  of  ox-gall,  given  with  a  large  hatid 
syringe  under  considerable  pressure,  to  be  of  great  value.  The  soft  rectal 
tube  was  inserted  as  high  as  possible.  If  vomiting  or  distention,  no  food 
at  all  until  this  ceases;  thirst  may  be  relieved  by  moistening  the  mouth, 


88o  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

sucking  a  piece  of  lemon  or  orange,  and,  if  necessary,  by  hypodermoclysis, 
rectal  saline  enemata,  or  proctoclysis.  Milk  is  objectionable,  as  it  forms 
curds  and  helps  fill  the  bowels.  Br®ths  and  soups  should  be  given  until 
the  accumulation  has  been  removed.  This  only  refers  to  after  the 
subsidence  of  acute  symptoms  and  after  the  bowels  have  acted.  No  food  is 
given  before  this  time.  Strychnin  by  hypodermic,  %q  to  3^0  grain  (0.00108 
-0.0021)  three  or  four  times  a  day,  can  be  given  as  a  stimulant.  It  also 
helps  tone  up  the  bowel.  Tincture  of  belladonna  in  large  doses,  admin- 
istered up  to  physiologic  symptoms,  10  drops  (0.59)  three  or  four  times  a 
day,  is  of  service,  as  soon  as  it  can  be  retained.  Later,  olive  oil,  2  to  4 
ounces  (60.0-125.0),  can  be  given  several  times  a  day  by  mouth.  On  the 
second  or  third  day,  if  matters  are  progressing  favorably,  give  cathartics, 
calomel,  castor  oil,  etc.,  by  mouth.  Massage  and  external  electricity  are 
of  value  in  these  cases  after  the  acute  symptoms  have  subsided.  I  have 
frequently  employed  electric  enteroclysis.  I  have  seen  it  take  several 
weeks^  to  completely  empty  the  bowel. 

2.  The  second  class  of  cases  in  which  medical  treatment  is  indicated 
is  in  dynamic  ileus.     The  indications  are: 

(a)  Abolition  of  food. 

{b)  Relief  of  thirst,  as  previously  indicated. 

(c)  Frequent  lavage  to  relieve  intra-abdominal  tension  and  also 
vomiting. 

{d)  Frequent  enteroclysis  (recurrent)  with  hot  normal  saline  solu- 
tion at  115°  to  i2o°F.,  several  gallons  being  used,  a  small  part  being  kept 
in  the  intestines  (preferably).  High  enemata^  with  soapsuds,  olive  oil, 
and  glycerin  are  also  of  service. 

{e)    Electric  enteroclysis. 

(/)  Tincture  of  belladonna,  10  drops  (0.59),  given  three  or  four  times 
a  day  up  to  physiologic  symptoms.  Strychnin,  >^o  grain  (0.002),  every 
four  hours. 

(g)  Magnesium  sulphate  (saturated  solution)  by  rectum,  4  ounces 
(125.0).  Heat  locally  is  of  value,  and  in  one  case  the  continuous  local 
application  of  the  ice-bag  stimulated  the  bowels  to  contract.  I  prefer 
the  ice-bag  in  many  cases,  unless  collapse  is  present. 

Cathartics  by  mouth  immediately  after  lavage,  especially  calomel, 
5  grains  (0.3),  crushed  up  in  water  and  poured  in  through  the  stomach- 
tube  at  the  end  of  the  washing.  Plain  water  and  no  saline  solution  should 
be  employed  for  lavage  when  calomel  is  administered.  Physostigmin 
sulphate  (eserin),  3^00  to  3^0  grain  (0.0006-0.001),  every  two  to  three 
hours  for  three  doses.  It  should  be  arranged  to  give  strychnin,  }>io  grain, 
with  each  dose.  Hormonal  and  pituitary  extract  are  also  suggested  as 
described  under  treatment  of  acute  dilatation  of  the  stomach.  Some 
recommend  elaterin,  }{q  grain.  If  all  methods  fail  and  the  patient  is 
rapidly  losing  ground,  then  simple  enterostomy  of  the  most  distended 
loop,  under  cocain,  as  suggested  by  Elsberg  in  obstructive  ileus,  I  believe, 
is  indicated.  This  procedure  allows  the  escape  of  gas  and  some  contrac- 
tion of  the  intestines  to  take  place.     Magnesium  sulphate  solution  should 

1  When  acute  symptoms  have  subsided,  olive  oil  or  mineral  oil  through  the  duode- 
nal tube  may  be  of  value.     See  Enteroclysis. 

*  Alum  5i  to  one  to  two  quarts  of  water  by  enema  is  also  useful. 


INTESTINAL   OBSTRUCTION — ACUTE   AND    CHRONIC  88 1 

be  injected  through  the  opening,  and  the  procedures  already  suggested 
should  be  continued.  Drainage  should  be  closed  after  twenty-four  hours. 
In  my  own  experience  I  have  had  good  restdts  from  continuous  and  active 
medical  treatment.  The  lavage  followed  by  catharsis  by  mouth  is  of  equal 
importance  as  the  enteroclysis.     Proctoclysis  is  not  sufficiently  active. 

Obstruction  by  Foreign  Bodies. — If  the  obstruction  is  by  accumu- 
lation of  fruit  stones,  an  enterolith,  or  a  gall-stone,  and  the  case  is  seen 
on  the  first  day  of  attack,  lavage  and  the  administration  of  4  ounces 
(125  c.c.)  of  olive  oil  through  the  stomach-tube  aids  to  lubricate  its 
passage,  followed  by  enteroclysis.  No  cathartic  should  be  given  by  mouth. 
If  the  mass  begins  to  come  away  and  symptoms  are  relieved  at  once,  then 
delay;  otherwise,  operate. 

If  the  case  is  seen  later,  with  progressive  symptoms,  use  lavage  and 
enteroclysis  to  relieve  distention  and  operate  at  once. 

Intussusception. — With  infants  or  young  children  the  stomach  should 
first  be  washed  out  to  relieve  abdominal  tension.  An  anesthetic  is 
then  administered  and  the  child  placed  in  the  Trendelenburg  position, 
and  an  attempt  at  reduction  may  then  be  made  by  inflation.  A  bellows 
is  attached  to  a  catheter,  and  the  air  should  be  injected  slowly,  the  but- 
tocks being  held  together.  The  best  guide  to  the  amount  introduced  is 
the  tension  of  the  abdominal  walls;  if  tension  is  marked  some  air  is  allowed 
to  escape. 

This  procedure  should  not  occupy  over  fifteen  or  twenty  minutes.  . 

A  saline  solution,  milk  and  water,  or  thin  gruel  at  a  temperature  of 
100°  to  io5°F.,  for  the  relaxing  effect  can  be  employed  instead  (as  sug- 
gested by  Holt).  The  fluid  is  suspended  in  a  fountain  syringe  4  or  5 
feet  above  the  patient's  head,  the  tension  of  the  abdomen  being  watched. 
Otherwise  the  procedure  is  the  same. 

Reduction  is  indicated  by  a  rumbling  sound  and  by.  the  abdomen 
resuming  its  natural  contour,  with  the  disappearance  of  the  tumor;  in 
some  cases  a  gush  of  feces  follows. 

If  these  symptoms  are  absent,  the  abdomen  is  examined  while  the 
patient  is  still  under  chloroform,  especially  the  right  ihac  fossa,  for  the 
continued  presence  of  the  tumor. 

It  is  better  not  to  repeat  the  injection. 

If  the  tumor  is  present,  or  if  vomiting  continues  and  no  gas  or  feces 
are  expelled,  or  the  pulse  and  temperature  rise,  immediate  operation  is 
indicated. 

This  method  of  taxis  should  be  tried  on  the  young  in  an  early  stage 
(the  first  day) ;  if  later,  operate.  If,  on  the  other  hand,  there  is  immediate 
improvement,  small  doses  of  opium  are  given  for  a  few  days  to  prevent 
re-invagination. 

Surgery. — In  all  other  cases  of  acute  intestinal  obstruction  except 
those  noted,  early,  preferably  immediate,  operation  is  indicated. 

A  large  percentage  of  fatalities  imputed  to  operation  are  due  io'd^eYscf 
on  the  part  of  the  physician;  thus,  in  strangulation,  volvulus,  intussus- 
ception, and  obstruction  from  foreign  bodies  (except  under  the  condition 
of  the  rapid  passage  of  foreign  bodies,  as  noted  above),  immediate  opera- 
tion is  indicated.  The  earlier  the  operation  the  better  the  prognosis. 
56 


882  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

In  these  cases  cathartics  should  never  he  given,  the  bowel  should  not 
he  massaged,  nor  electricity  used. 

Puncture  of  the  bowel  through  the  abdominal  wall  to  relieve  gas  is  absolutely 
dangerous — an  invitation  to  peritonitis. 

Laxatives  do  positive  harm.  The  attempted  diagnosis  of  the  seat  of 
the  acute  obstruction  by  the  administration  of  bismuth  by  mouth  and 
the  use  of  .x--rays,  which  necessitate  a  delay  of  six  hours  or  more,  should 
never  be  undertaken.  Bismuth  or  barium  enema,  followed  by  the  x-rays 
is  only  of  use  in  determining  obstruction  in  the  large  intestine.  It  is  of 
value  in  chronic  cases,  but  not  advisable  in  acute  ones. 

Lavage  (frequent)  is  of  first  importance;  it  lessens  intra-abdominal 
tension  and  also  the  pain,  makes  diagnosis  easier,  and  in  some  cases  has 
actually  proved  curative  as  in  intussusception.  This  last  is  explained 
by  the  fact  that  the  gastro-intestinal  distention  is  relieved  above  the 
point  of  obstruction,  and  occasionally  the  gut  escapes  from  the 
constriction. 

If  the  patient  is  seen  on  the  first  day  of  the  attack,  lavage  should  be 
given  at  least  twice,  one  or  two  hours  apart,  while  preparing  for  operation; 
if  later,  then  once  before  operation. 

Enteroclysis  at  115°  to  i20°F.  is  of  value  to  lessen  the  distention  due 
to  general  paresis  and  improve  the  pulse;  if  the  intussusception  lies  in 
the  rectum,  irrigation  is  contra-indicated. 

No  fluid  or  ice  by  mouth,  but  the  tongue  can  be  moistened  and  small 
normal  saline  injections  or  proctoclysis  be  administered  for  thirst.  These 
methods  also  relieve  postoperative  thirst.  Heat  or  cold  to  abdomen. 
Hypodermoclysis  and  infusion  if  there  is  shock. 

Lavage  often  relieves  the  pain,  but  if  this  is  very  severe,  morphin, 
}4  grain  (0.016),  by  hypodermic,  and  repeat  to  lessen  shock.  All  these 
methods  are  of  use  while  preparing  for  immediate  operation. 

The  general  medical  methods  of  treatment  by  opium  or  morphin  for 
three  or  four  days  and  expectant  treatment,  with  subsequent  operative 
fatality,  are  to  be  deplored. 

Operate  in  acute  peritonitis.  Subsequent  to  operation,  lavage,  if 
vomiting,  and  nutritive  enema ta;  no  food  or  water  by  mouth;  later,  a 
little  hot  water.  Proctoclysis  is  of  value  for  the  sepsis.  Open  bowels  by 
enema  or  enteroclysis  in  twenty-four  to  forty-eight  hours,  as  intestinal 
paresis  is  usually  present;  earlier  if  the  symptoms  persist  which  are  due  to 
this  condition. 

Rectal  injection  of  400  c.c.  (12  ounces)  of  7  to  8  per  cent,  salt  solution 
in  intussusception  to  produce  reversed  peristalsis  has  been  suggested  by 
Riegel.  Experimentally  it  has  proved  efficacious,  but  practically  I  am 
dubious  of  its  value,  as  most  cases  of  intussusception  are  adherent  or 
strangulated. 

In  desperate  cases  enterostomy  with  drainage  of  the  intestines,  done 
under  local  anesthesia  (cocain),  is  advisable.  A  few  hours  later  (within 
twenty-four  hours)  radical  operation  with  relief  of  the  obstruction  can  be 
performed.     Elsberg^  holds  that  prehminary  enterostomy,  leaving  the 

*  The  Value  of  Enterostomy  and  Conservative  Operative  Methods  in  the  Surgical 
Treatment  of  Acute  Intestinal  Obstruction,  Ann.  Surg.,  May,  1908. 


INTESTINAL   OBSTRUCTION— ACUTE    AND    CHRONIC  883 

prolonged  search  for  the  obstruction  for  a  second  operation,  to  be  more 
frequently  advisable. 

CHRONIC  INTESTINAL  OBSTRUCTION 

In  this  condition  there  is  a  stenosis  or  narrowing  of  the  lumen  of  the 
intestines,  but  the  obstruction  is  not  acute  and  complete  in  the  earlier 
stages,  but  comes  on  gradually. 

Etiology. — It  may  be  caused  by  the  same  factors  which  produce  acute 
obstruction,  if  the  entire  lumen  of  the  canal' is  not  occluded. 

One  of  the  most  frequent  causes  of  chronic  obstruction  is  stricture 
resulting  from  ulcers  or  new  growths.  The  latter,  even  if  they  do  not 
occupy  the  entire  canal,  may  protrude  at  one  point  and  partially  occlude 
the  intestines.     They  may  be  benign  or  malignant. 

In  addition  we  have  the  peculiar  tumor-like  tuberculosis  of  the  cecum, 
which  causes  a  progressive  stenosis,  and  chronic  peridiverticulitis  (sig- 
moiditis) may  produce  a  narrowing  of  the  lumen  with  symptoms.  Both 
of  the  latter  conditions  often  simulate  carcinoma. 

Strictures  resulting  from  ulcers  involve  the  large  intestines  much  more 
frequently  than  the  small,  probably  in  a  ratio  of  6  to  i,  according  to 
Treves. 

Among  the  causes  of  stricture  are  tubercular,  stercoral,  syphilitic, 
typhoid,  dysenteric,  and  duodenal  ulceration. 

Woodward^  has  demonstrated  that  dysenteric  ulcers  rarely  cause 
intestinal  stricture,  and  Nothnagel  agrees  with  him.  Stercoral  and 
tubercular  ulcers  are  a  quite  frequent  cause,  as  is  also  syphilitic  ulceration. 
Typhoid  ulcers  are  a  rare  cause. 

There  are  other  rare  factors  reported,  such  as  ulceration  in  a  portion 
of  the  bowel  that  has  been  incarcerated,  or  stricture  following  the  slough- 
ing off  of  invaginated  intestines.  A  few  cases  of  traumatism  with  damage 
to  the  intestines  and  subsequent  stricture,  or  of  a  circumscribed  peritonitis 
with  adhesions,  following  trauma,  and  subsequent  stenosis  have  been 
reported.  Carcinoma  of  the  pancreas,  or  chronic  pancreatitis  with  en- 
largement of  the  head  of  the  pancreas,  enlargement  of  the  retroperitoneal 
glands,  and  gall-stones  may  cause  stricture.     A  stricture  may  be  congenital. 

Rectal  strictures  are  quite  frequent,  and  much  more  so  in  women,  as 
from  syphilitic,  tubercular,  stercoral,  and  hemorrhoidal  ulcers.  Opera- 
tion for  prolapse  of  rectum  or  for  hemorrhoids,  especially  the  Whitehead 
operation,  traumatism  from  the  syringe-tip,  or  the  introduction  of  foreign 
bodies  may  produce  stricture. 

Traumatism  from  the  child's  head  during  parturition  may  be  a  cause. 

Gonorrheal  abscess  of  the  Bartholin  glands  may  lead  to  ulceration 
of  the  rectum  and  stricture  ultimately  results. 

Adhesions  may  be  a  frequent  cause  of  chronic  stenosis,  sometimes 
of  rather  a  mild  type  with  persistent  constipation  of  long  duration  as 
the  chief  symptom,  but  no  actual  obstruction.  The  Lane  kink  due  to 
adhesions  of  the  ileocecal  junction,  various  angulations  in  extreme  enterop- 
tosis  not  relieved  by  medical  treatment  and  prolapse  of  the  sigmoid  may 
'  Medical  and  Surgical  History  of  the  War  of  the  Rebellion. 


884  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

be  causes.  In  a  recent  case  of  T.  A.  Gonzales,  seen  by  the  writer  in  con- 
sultation, a  point  of  stenosis  was  found  at  the  sigmoidorectal  junction  due 
to  adhesions,  but  more  marked  and  unsuspected  adhesions  were  demon- 
strated by  S.  Tousey  by  a  rontgenograph.  The  case  was  successfully 
operated  on  by  Parker  Sims,  confirming  the  x-ray  diagnosis. 

Anatomy  of  Chronic  Stenosis  of  tiie  Intestines. — The  intestines  below 
the  stenotic  area  are  empty  and  contracted  and  the  bowel  normal.  Above 
the  point  of  stenosis  the  bowel  is  dilated,  often  to  a  great  degree,  and  may 
form  a  sac-like  pouch.  The  dilatation  may  involve  only  a  short  part  of 
the  bowel  above  the  stenosis. 

In  some  cases  there  is  considerable  distention  from  gas  and  the  ab- 
domen may  assume  the  barrel  shape.  The  degree  of  distention  depends  on 
the  tightness  of  the  stricture.  There  is  stagnation  of  the  intestinal 
contents  above  the  stricture,  which  causes  mechanical  distention  and  may 
stimulate  the  peristaltic  action.  This  material  also  acts  as  an  irritant. 
When  the  musculature  is  stimulated  to  increased  activity  hypertrophy  is 
thus  produced.  This  accounts  for  the  violent  visible  peristaltic  movements 
in  chronic  obstruction. 

Patel  claims  that  in  stenosis  from  external  pressure  we  have  dilatation 
without  hypertrophy,  and  that  the  latter  only  occurs  if  ulcers,  which  cause 
contraction  through  irritation,  are  present.  This  would  explain  the  oc- 
currence of  hypertrophy  without  stenosis  in  some  cases  of  intestinal 
ulceration. 

Changes  in  the  mucosa  and  submucosa  are  frequently  present,  a 
catarrhal  condition  and  ulceration  (stercoral).  General  peritonitis,  local 
peritonitis,  or  local  abscess  may  result. 

The  intestines  may  become  elongated  above  the  stenosis. 

Location  of  Stenosis. — The  large  intestine  is  the  most  common  seat 
of  the  stricture.  Syphilitic,  dysenteric,  and  stercoral  strictures  are  chiefly 
localized  here,  as  are  also  those  resulting  from  traumatism  or  from  follicular 
ulceration. 

Tuberculous  ulceration  produces  stricture  most  commonly  in  the 
small  intestine,  though  tuberculous  tumor  is  found  in  the  cecum,  and 
probably  tuberculous  ulcer  is  more  frequent  in  the  rectum  than  has  been 
usually  credited.     Tuberculosis  of  the  sigmoid  also  occurs. 

Malignant  strictures  are  most  frequent  in  the  large  intestine. 

If  the  ulcer  producing  the  stricture  lies  parallel  to  the  longitudinal 
axis  of  the  bowel,  stenosis  is  not  as  marked  as  when  it  is  an  annular 
ulcer  (girdle  ulcer).  The  stricture,  as  a  rule,  is  short  and  the  external 
aspect  of  the  intestine  looks  as  if  a  ribbon  had  been  tied  about  it.  The 
external  surface  of  the  gut  is  often  covered  with  exudate,  so  that  the  bowel 
is  thickened  and  there  may  be  adhesions  between  the  intestines  and 
other  loops  or  other  viscera,  which  further  constrict  the  intestines. 

The  stricture  consists  of  cicatricial  tissues  unless  malignant.  Folds 
of  mucous  membrane  near  the  cicatrix  or  hypertrophic  polypoid  protrusion 
of  mucous  membrane  may  aid  in  closing  the  gut. 

If  there  are  numerous  stenoses,  as  from  tubercular  ulcers,  there  may 
be  sacculated  dilatation  of  the  small  intestine  between  the  stenosed 
points. 


INTESTINAL   OBSTRUCTION^ — ACUTE    AND    CHRONIC  885 

Symptoms. — These  depend  upon  the  cause  of  the  obstruction;  malig- 
nant growth  must  be  differentiated  cUnically  from  benign  conditions. 
The  symptoms  generally  come  on  gradually. 

In  stenosis  of  the  small  intestine  they  may  be  latent  for  a  considerable 
time,  on  account  of  the  fluidity  of  the  bowel  contents,  and  then  appear 
with  rapidity.  On  the  other  hand,  stenosis  of  the  colon  produces 
symptoms  more  rapidly  on  account  of  the  solid  contents. 

As  a  rule,  constipation  is  one  of  the  earliest  symptoms,  and  this  gradu- 
ally becomes  worse.  The  patient  complains  of  digestive  disturbances  and 
swelling  of  the  abdomen,  there  are  loss  of  appetite,  and  nausea.  Stenotic 
feces  in  round  balls,  cylinder  (pipe-stem)  or  tape-like  movements,  are 
suggestive,  but  not  conclusive.  This  type  of  feces  may  occur  in  spastic 
constipation  and,  on  the  other  hand,  the  feces  may  be  normal  in  form 
with  a  stricture  high  up.  Diarrhea  at  times  alternates  with  constipation. 
The  diarrheal  movements  may  be  extremely  offensive  and  contain  mucus, 
or  even  pus  and  blood;  this  last  is  especially  true  in  malignant  stenosis, 
where  there  are  active  ulcerations,  or  in  intussusception.  The  diarrhea 
often  relieves  the  patient.  We  must  remember  that  chronic  diarrhea  is 
present  in  some  cases  when  there  is  a  marked  catarrh  above  the  stricture, 
and  this  will  sometimes  lead  one  astray.  Severe  pain  of  a  colicky  type 
occurs  in  all  cases,  and  this  may  at  times  be  excruciating;  it  may  be 
localized  near  the  seat  of  stricture,  but  in  other  cases  be  more  diffuse, 
radiating  even  toward  the  thorax  and  producing  a  feehng  of  oppression 
and  dyspnea.  A  symptom  which  occurs  with  the  colic,  which  can  be 
considered  pathognomonic,  is  the  visible  peristaltic  movement  of  the  intes- 
tines, in  which  the  loops  can  be  seen  to  stiffen  and  relax  alternately.  The 
coils  appear  and  disappear.  Peristaltic  unrest  (intestinal)  is  not  always 
present,  especially  in  the  earlier  stages  of  the  disease;  and  at  times,  late 
in  the  condition,  the  bowel  may  become  fatigued  and  paretic  from  over- 
distention.  Often,  however,  the  peristaltic  movements  will  aid  in  locating 
the  position  of  the  obstruction. 

Vomiting  may  not  occur  at  first,  but  is  later  more  frequent,  and  if 
finally  the  obstruction  becomes  complete,  may  be  marked  and  even 
feculent.     Gurgling,  rolling  sounds,  and  meteorism  are  present. 

Location  of  the  Obstruction. — This  influences  the  character  of  the 
symptoms.  If  the  stenosis  is  situated  above  Vater's  papilla,  the  symp- 
toms are  similar  to  those  of  stenosis  of  the  pylorus.  Marked  dilatation 
of  the  stomach,  nausea,  and  vomiting  are  prominent.  R.  T.  Morris  has 
demonstrated  that  in  some  cases  of  spider  adhesions  from  the  gall-bladder 
there  may  be  severe  hemorrhage  and  pain  which  may  simulate  gastric 
ulcer.  There  is  usually  a  history  of  previous  gall-bladder  disease.  If  the 
obstruction  lies  below  Vater's  papilla,  we  again  have  gastric  dilatation, 
but  frequent  biUous  vomiting.  The  stomach  contents  are  neutral  or 
alkaline,  due  to  regurgitation  of  pancreatic  juice  and  bile,  and  duodenal 
digestion  takes  place  within  the  stomach.  With  stenosis  above  the  papilla, 
gastric  contents,  as  in  benign  pyloric  stenosis,  are  acid.  Riegel  states 
another  sign  of  duodenal  stenosis  is,  that  when  the  stomach  has  been 
emptied  the  night  before,  twelve  hours  later  as  much  as  3  liters  (quarts) 


886  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

can  be  frequently  aspirated.  The  reaction  and  contents  differ  from  that 
gastrosuccorrhea. 

The  lower  down  the  obstruction,  the  less  pronounced  the  gastric 
symptoms,  as  a  rule,  and  the  more  marked  the  constipation  and  colicky 
pains.  There  may  even  be  an  absence  of  gastric  symptoms  for  a  con- 
siderable period  if  the  stenosis  be  in  the  lower  ileum  or  in  the 
colon.  The  symptoms,  however,  are  always  more  severe  in  chronic 
intussusception  or  chronic  types  of  strangulation  than  in  ordinary 
cicatricial  stenosis. 

X-rays. — The  administration  of  barium  or  bismuth  by  mouth  and 
inspection  six  to  twelve  hours  later  with  the  fluroscope  or,  preferably,  by 
radiography  may  demonstrate  the  location  of  the  stenosis.  If  it  be 
apparent  in  the  large  intestine  a  high  injection  of  bismuth  and  olive  oil 
or  bismuth  suspended  in  water  or  of  barium  is  given,  in  addition,  6  to  12 
hours  later,  and  the  examination  is  then  made  again.  These  procedures 
are  not  to  be  recommended  in  acute  cases,  though  valuable  in  the  chronic 
Jor  diagnosis.  In  the  less  marked  cases  of  stenosis  as  from  adhesions  of 
mild  type  radiography  both  in  the  standing  and  Trendelenburg  positions 
after  the  barium  enema  should  be  carried  out. 

Inspection  of  the  Abdomen. — When  the  stenosis  is  high  up  in  the 
small  intestine  there  is  apt  to  be  distention  of  the  epigastric  region,  and 
when  in  the  lower  part  of  the  small  intestine  or  in  the  large  intestine,  then 
there  is  considerable  abdominal  distention. 

The  active  peristaltic  contraction  of  the  intestines  is  marked,  the  coils 
(stiffened)  rising  and  falling,  and  often  performing  winding  or  vermicular 
motions.  These  movements  are  associated  with  colicky  pains  and  with 
gurgling  and  rolling  noises. 

Sausage-shaped  ridges  may  appear  with  depressions  in  their  vicinity, 
and  in  a  few  seconds  the  ridges  disappear  in  one  part  and  appear  in 
another,  the  coils  never  remaining  visible  in  one  place  for  any  length  of 
time.  They  appear  hard  and  stiff  to  the  hand  and  then  suddenly  become 
elastic.        • 

The  contractions  in  the  small  intestine  are  usually  smaller  than  in  the 
large  intestine. 

Meteorism  in  the  milder  cases  is  not  marked,  as  the  gas  can  pass 
the  obstruction.  Later  it  may  become  quite  marked,  and,  as  in  acute 
obstruction,  may  be  local  or  general  in  character. 

If  the  obstruction  is  in  the  lower  colon  or  rectum,  it  will  be  most  pro- 
nounced at  first  in  the  course  of  the  colon,  on  the  sides  of  the  abdomen, 
and  in  the  epigastrium. 

If  the  obstruction  is  in  the  lower  ileum,  the  distention  is  more  pro- 
nounced in  the  umbilical  and  hypogastric  regions  and  there  may  be 
the  ladder-pattern  of  distention,  and  the  lumbar  regions  are  relaxed 
(undistended). 

Later  there  may  be  more  general  distention  and  the  barrel-shaped 
abdomen.  Local  manifestations  of  meteorism  are  described  under 
Acute  Obstruction. 

One  of  the  important  types  is  chronic  intussusception,  which  may 
develop  after  an  acute  attack  has  subsided  or  may  occur  as  such  from  its 


INTESTINAL    OBSTRUCTION — ACUTE    AND    CHRONIC  887 

incipiency.  It  takes  place  most  frequently  in  the  ileocecal  form.  Some 
of  the  latter  cases  may  continue  for  months  or  even  years.  The  pain  is 
paroxysmal,  but  may  entirely  intermit.  There  may  be  attacks  of  pain 
daily,  or  every  few  days  or  weeks.  As  the  disease  advances  the  intervals 
grow  shorter.  Vomiting  is  not  marked.  Often  diarrhea  is  present,  or 
constipation  alternating  with  diarrhea.  Blood  may  be  passed  and 
tenesmus  is  at  times  present.  Palpation  shows  the  presence  of  a  tumor 
in  about  50  per  cent,  of  the  cases,  or  a  tumor  can  be  felt  in  the  rectum. 
Local  meteorism  may  be  present.  Occasionally  the  invaginated  part  may 
slough  off  and  perfect  recovery  ensue  or,  again,  ultimate  stenosis  may 
follow.     Death  may  occur  through  perforation. 

Chronic  Obstruction  through  Fecal  Accumulation. — This  is  more 
common  in  females  and  usually  in  our  older  patients.  The  history  is  of 
habitual  constipation.  At  times  large  amounts  of  fecal  matter  are  voided 
by  enema.  Scybalae  are  frequently  present.  Rectal  examination  may 
show  impaction.  There  are  digestive  disturbances,  flatulence,  loss  of 
appetite,  eructation,  fetid  breath,  headache,  dizziness  and  symptoms  of 
auto-intoxication;  there  may  be  oppression  in  breathing  from  distention, 
an  unhealthy  appearance  of  the  skin,  and  a  foul  tongue.  There  may  be 
pains  in  the  thighs,  legs,  and  genitals  due  to  pressure  on  the  lumbar  or 
sacral  nerves.     The  patient  may  be  very  neurasthenic. 

Distention  and  gurgling  may  occur.  There  are  colicky  pains,  but 
usually  they  are  not  severe. 

If  untreated,  the  condition  may  become  worse,  the  constipation 
increases,  and  all  the  symptoms  of  chronic  or  even  of  acute  obstruction 
develop,  as  already  described  under  Fecal  Obstruction.  The  vomiting 
may  even  become  feculent. 

Harris^  however  reports  a  case  of  fecal  impaction  in  the  ileum  for  fifty- 
three  days  with  recovery. 

Palpation  shows  the  presence  of  a  tumor  frequently  in  the  colon,  espe- 
cially in  the  cecum,  sigmoid,  or  other  flexures.  It  may  be  hard  and 
uneven,  and  will  often  "pit"  on  pressure.  It  is  not  painful  on  pressure, 
as  a  rule.  Rectal  examination  generally  shows  the  presence  of  scybalse. 
I  have  treated  a  case  in  which  apparently  nearly  the  entire  abdomen  was 
occupied  by  the  fecal  tumor.  Operation  for  "tumor"  had  been  advised. 
As  a  result  of  80  bowel  movements  in  one  week  the  tumor  disappeared. 
The  patient  had  had  no  bowel  action  for  three  weeks.  Enemata,  and 
especially  recurrent  rectal  irrigation,  and  later,  catharsis  will  reduce  the 
size  of  the  tumor.  I  have  seen  cases  in  which  acute  flexions  or  angulations 
of  the  sigmoid  and  colon  have  been  factors  in  the  production  of  this 
condition.  They  are  well  described  by  the  late  J.  P.  Tuttle.^  Gant 
has  also  demonstrated  that  prolapse  of  the  sigmoid  flexure  is  a  cause,  and 
relief  has  been  secured  by  suspension  of  the  sigmoid. 

Rectal  Stricture. — There  are  the  symptoms  of  progressive  constipa- 
tion at  times  with  alternating  diarrhea,  with  mucus,  and  at  times,  pus  with 
traces  of  blood  in  the  stools,  colicky  pains,  tympanites,  tenesmus,  and  loss 

'Journal  A.  M.  .\.,  Mar.,  8,  1913. 
*N.  Y.  Med.  Jour.,  etc.,  Mar.  14,  1908. 


888  DISEASES    OF   THE    STOMACH   AND   INTESTESTES 

of  appetite.  There  may  be  hemorrhoids  and  rectal  prolapse.  Digital 
examination,  exploration  with  a  rectal  bougie  or  the  proctoscope,  will 
demonstrate  the  constriction. 

With  stricture  the  pressure  on  the  examining  finger  remains  constant 
and  is  not  like  sphincteric  spasm,  which  soon  relaxes.  Many  of  the 
strictures  are  within  the  finger  reach,  within  4  to  6  cm.  up  the  bowel; 
if  not  within  reach  but  suspected,  a  Wales  rectal  bougie  or  soft  tube  can 
be  employed  for  the  examination.  The  degree  .of  stricturing  can  be 
determined  by  using  tubes  or  bougies  of  varying  sizes.  It  is  preferable 
to  pass  the  speculum  up  to  the  point  of  stricture,  so  as  to  examine  its  nature 
thoroughly.  It  is  often  advisable  to  remove  a  small  section  under  cocain 
for  microscopic  examination.  With  malignant  stricture  there  are 
cachexia,  loss  of  weight,  metastases,  and  the  symptoms  described  under 
Carcinoma. 

Complications. — Above  the  stenosis  on  account  of  the  ulceration  we 
may  have  circumscribed  peritonitis  and  abscess  or  perforation  with 
general  peritonitis.  The  abscess  may  rupture  into  other  viscera  or 
perforate  the  abdominal  wall.  The  chronic  condition  may  suddenly 
become  acute,  and  severe  collapse  occur  with  death,  or  thrombosis  of 
some  of  the  veins,  or  pyemic  processes,  or  the  patient  may  die  of  inanition 
or  become  bed-ridden  and  die  of  hypostatic  congestion  of  the  lungs. 

Diagnosis. — The  gradually  increasing  constipation;  colic  attacks  with 
frequent  stoppage  of  the  bowels,  alternating  at  times  with  diarrhea  and 
the  temporary  relief  of  symptoms;  visible  peristaltic  movements  with 
tetanic  rigidity  of  the  intestines;  at  first  local  meteorism  and,  later, 
the  tendency  to  the  barrel-shaped  abdomen;  the  presence  of  gastro-in- 
testinal  disturbances  of  varying  degree  and,  frequently,  loss  of  weight 
are  suggestive  of  the  obstruction.  Rectal  examination  is  always  of 
importance. 

If  the  constipation  is  of  long  standing,  in  an  elderly  person  or  invalid, 
and  there  is  no  cachexia,  the  tumor  movable  and  doughy  on  pressure, 
scybalae  being  passed,  and  at  times  accumulation  felt  in  the  rectum,  fecal 
tumor  is  evident.  These  occur  chiefly  in  the  caput  coli,  sigmoid,  colon 
flexures,  or  rectum. 

With  carcinoma  there  is  marked  cachexia  and  the  tumor  is  hard  and 
solid,  occurs  mostly  in  the  caput  coli,  sigmoid,  and  most  frequently  in  the 
rectum,  and  more  frequently  in  persons  over  forty-five.  There  is  slight 
or  moderate  leukocytosis,  and  also  anemia.  In  the  scirrhous  type  of 
carcinomatous  stricture,  cachexia  may  be  scarcely  noticeable  for  a  con- 
siderable period.  The  progressive  constipation  and  age  of  the  patient 
are  significant  together  with  increasing  anemia. 

Tuberculous  tumor  of  the  cecum  and  peridiverticulitis  (chronic)  of 
the  sigmoid  must  be  held  in  consideration  as  causes. 

With  chronic  intussusception  the  mass  is  usually  of  sausage  shape,  and 
shows  the  peculiarity  that  it  sometimes  feels  hard  and  sometimes  soft  on 
palpation;  there  are  mucus  and  blood  in  the  stool. 

External  tumors  can  generally  be  appreciated.  Vaginal  Examination 
should  be  made.  If  there  have  been  attacks  of  peritonitis,  bands  and 
adhesions  would  be  suspected. 


INTESTINAL    OBSTRUCTION — ACUTE   AND    CHRONIC  889 

A  previous  history  of  diarrhea,  dysentery,  syphilis,  or  tubercular 
difl&culty  would  suggest  ulcerative  stenosis. 

Stricture  of  the  small  intestine  is  most  frequently  due  to  adhesiotis 
or  tubercular  ulcer.  In  the  large  intestine  stercoral,  syphilitic,  or 
dysenteric  ulcers  are  to  be  considered,  chiefly  carcinoma  or  pelvic  inflam- 
mation, perityphilitic  adhesions,  and,  more  rarely,  tuberculosis  of  the 
cecum  and  chronic  peridiverticulitis. 

Course  and  Prognosis. — This  depends  on  the  etiology  and  severity  of 
the  obstruction.  With  non-malignant  stricture  of  the  bowel  of  moderate 
type,  or  in  the  fecal  obstruction  cases,  not  progressive,  the  patient  by 
proper  regulation  of  diet  may  live  many  years.  With  malignancy  the 
prognosis  is  fatal  unless  relieved  by  early  operation;  chronic  intussuscep- 
tion occasionally  clears  up,  but  the  prognosis,  as  a  rule,  is  bad.  In  pro- 
gressive cases  the  S5anptoms  rapidly  become  worse  and  life  is  shortened, 
with  death  from  final  acute  obstruction.  Unless  radical  operation  is 
performed,  complications  such  as  peritonitis,  pyemic  processes,  etc.,  hasten 
the  final  result. 

Treatment. — If  chronic  obstruction  suddenly  or  gradually  develops 
into  acute  obstruction,  the  same  indications  for  treatment  exist  as  in  the 
latter  condition. 

In  the  chronic  cases  the  proper  regulation  of  diet,  omitting  those  things 
which  will  mechanically  fill  up  the  intestines  and  a  careful  regulation  of 
the  bowels,  are  most  important.  Substances  that  give  a  large  residue  of 
fecal  matter,  which  are  irritating  and  extremely  constipating,  should  be 
excluded. 

Matzoon,  koumiss,  buttermilk,  bacillac,  fermillac,  lactone-buttermilk, 
and  kefir  milk  are  excellent.  Milk  agrees  well,  as  a  rule,  with  most  cases 
and  is  readily  digested,  while  others  it  constipates  and  is  undigested. 

Raw  eggs  can  be  beaten  up  in  milk,  and  soft-boiled  eggs,  broths,  soups, 
and  gruels  administered.  Tropon  and  somatose  are  of  value,  administered 
in  the  broths  or  milk. 

If  the  stenotic  symptoms  are  progressive  or  fairly  marked,  liquid  or 
soft  diet  alone  should  be  given. 

In  milder  cases  scraped  beef,  tender  meat  (well  divided),  butter,  a 
small  amount  of  well-toasted  bread,  and  moderate  in  quantity,  rice,  sago, 
and  mashed  potatoes  in  small  amount  are  admissible.  The  patient  should 
eat  a  small  quantity  frequently  and  should  take  sufficient  food  to  preserve 
his  nutrition.  Very  hot  and  cold  drinks  should  be  avoided.  Irritating 
food,  such  as  mustard,  spices,  pepper,  vinegar,  fruits  in  bulk,  and  green 
vegetables  in  large  amounts,  should  be  forbidden.  Substances  giving  a 
large  residue  of  fecal  matter  should  also  be  cut  off.  Spinach  I  have  found 
of  service  to  aid  bowel  action.     Fats,  such  as  cream  and  butter,  are  useful. 

Fresh  fruit  juices  are  valuable,  and  the  administration  of  a  glass  of 
water  on  rising  is  of  service. 

Bowels. — The  bowels  must  be  moved  every  day.  Injections  of  soap- 
suds enemata  of  medium  size,  not  over  i  quart  (Uter),  with  the  hips  ele- 
vated; Kussmaul's  method  of  oil  injection,  i  pint  (500  c.c.)  or  more, 
being  retained  over  night;  or  the  addition  of  olive  oil  to  the  enema,  mild 
cathartics,   such  as  cascara,   rhubarb,   syrup   of  figs,   phenolphthalein. 


890  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

regulin,  the  mineral  oils,  and  occasionally  sulphate  of  magnesia  or  Apenta 
water,  are  of  service.  Under  Chronic  Constipation  numerous  remedies 
are  described. 

Enteroclysis  (recurrent)  is  valuable  in  many  cases. 

Massage,  vibratory  massage,  and  electricity  are  of  service  only  in 
cases  due  to  fecal  accumulation. 

If  diarrhea  is  present,  unless  the  patient  is  weakened  thereby,  it 
should  not  be  checked.  In  the  latter  event  mild  preparations,  such  as 
bismuth  subnitrate,  chalk  mixture,  or  chalk  and  catechu,  are  preferable 
to  opiates.  If  there  are  small  diarrheal  movements,  evidently  a  diarrhea 
associated  with  constipation,  then  a  dose  of  castor  oil,  laxol,  or  a  saline 
cathartic  is  indicated. 

For  Colic  Attack  and  Peristaltic  Movements. — Hot  appUcations  to  the 
abdomen  are  indicated  and  a  recurrent  irrigation  of  normal  saline  solution 
at  115°  to  i2o°F.  is  of  value,  to  be  given  for  ten  to  twenty  minutes. 
The  latter  removes  gas  and  clears  the  bowels.  Enemata  also  can  be 
administered. 

Tincture  of  belladonna,  10  minims  (0.59),  once  or  twice,  is  of  use  to 
allay  spasm,  or  by  suppository,  extract  of  belladonna,  K  to  J^  grain 
(0.016-0.024).  Opium  I  avoid  if  possible,  and  then  only  }4  to  yi  grain 
(0.008-0.016)  of  morphin  or  codein  by  hypodermic.  It  should  be  given 
only  to  allay  severe  pain. 

For  vomiting  and  distention  lavage  is  indicated. 

Cerium  oxalate  with  bismuth  and  soda  will  check  vomiting,  also  i 
minim  (0.059)  doses  of  Fowler's  solution  of  arsenic  every  hour  for  four  doses. 

Cocain,  which  has  been  suggested,  is  a  dangerous  and  pernicious  drug. 
I  have  seen  complete  collapse  after  its  use  in  as  small  doses  as  1^0  grain 
(0.006). 

Lavage  is  of  special  value  in  temporarily  allaying  symptoms  if  the 
stenosis  is  in  the  small  intestine. 

If  there  is  chronic  fecal  impaction,  our  first  eforts  should  always  be 
directed  from  below. 

Hardened  scybalae  should  be  removed  from  the  rectum  by  the  finger, 
oil  injections,  and,  later,  by  soapsuds  enemata  and  recurrent  rectal 
irrigations.     Olive  oil  can  be  given  by  mouth. 

Later,  cathartics,  massage,  electricity,  and  vibratory  massage  are  of 
service. 

Electric  enteroclysis  I  have  found  useful  in  obstinate  cases  of  fecal 
impaction. 

Tincture  of  belladonna,  10  gtts.  (0.59)  three  or  four  times  a  day, 
and  strychnin,  }4o  grain  (0.002)  t.i.d.,  are  of  value.  Eserin  sulphate, 
Hoo  to  3^0  grain  (0.00065-0.00108),  may  be  required. 

Mild  cases  of  rectal  stricture,  providing  they  are  not  malignant,  can 
be  benefited  by  dilatation  for  ten  to  fifteen  minutes  every  two  to  three 
days  with  different  sized  bougies.  Operation  on  the  stricture  may  be 
necessary  in  some  cases.  Thiosinamin  can  first  be  tried,  injected  into  the 
bowel  or  by  hypodermic.  Dose,  H  to  i^  grains  (0.033-0.1);  or  by 
hypodermic,  i  grain  (0.065),  in  15  per  cent,  alcohol  solution  or  10  per  cent, 
glycerinated  solution. 


INTESTINAL   OBSTRUCTION — ACUTE   AND    CHRONIC  89 1 

Operation. — Most  types  of  chronic  intestinal  obstruction  grow;  worse, 
except  those  due  to  fecal  impaction.  In  mild  types  of  rectal  stricture  local 
dilatation  may  be  paUiative  and  keep  the  patient  comfortable. 

Malignant  growths  must  be  extirpated  as  soon  as  possible.  Stric- 
tures must  be  treated  according  to  their  location — in  the  rectum,  by  divi- 
sion and  dilatation  or  by  resection.  In  other  regions,  enteroplasty, 
splitting  the  gut  parallel  to  its  axis,  at  the  same  time  dividing  the  stricture 
and  uniting  the  incision  transversely,  has  been  successful.  Complete 
excision  may  be  necessary,  with  or  without  employing  Murphy's  button 
to  unite  the  ends.  Anastomosis  of  the  bowel  above  to  that  portion  lying 
below  the  stricture  may  be  required.  In  stricture  of  the  colon  in  cases 
quite  prostrated,  a  simple  colotomy  above  the  point  of  stenosis  is  indicated. 
Local  anesthesia  may  even  be  employed. 

Adhesions  should  be  severed  and  tumors  compressing  the  bowel  re- 
moved. If  the  chronic  obstruction  be  due  to  any  of  the  causes  which  may 
also  produce  acute  obstruction,  appropriate  surgical  measures  are 
indicated. 

Early  operation  is  preferable  in  most  cases  of  chronic  obstruction. 

In  acute  obstruction  engrafted  on  chronic  stenosis  there  should  be 
immediate  resort  to  surgery. 


CHAPTER  XXXIV 

VAGOTONIA— SYMPATHETICOTONIA— VISCERAL  CRISES  IN 
THE  ERYTHEMA  GROUP— UMBILICAL  DYSPEPSIA 

VAGOTONIA  AND  SYMPATHETICOTONIA.     THEIR  RELATION  TO 
GASTRO -INTESTINAL  SYMPTOMS 

In  the  study  of  functional  disturbances  of  the  gastro-intestinal  tract 
there  has  been  considerable  difference  of  opinion.  Some  believe  an 
anatomical  basis  to  be  the  source  of  these  abnormalities,  for  example 
that  ulcer  is  the  cause  of  hyperacidity,  or  hypersecretion;  others  that 
pure  gastric-intestinal  neuroses  are  fairly  common,  though  in  some  cases 
they  are  one  of  the  symptoms  of  hysteria  or  neurasthenia.  They  may 
also  undoubtedly  be  reflex  from  disease  of  some  other  organ.  Pure 
neuroses  of  the  gastro-intestinal  tract  are,  in  my  opinion,  extremely  rare. 

Eppinger^  and  Hess  in  their  recent  studies  of  the  "Vegetative  Nervous 
System,"  hold  that  a  certain  constitutional  defect  exists  in  some  persons, 
which  manifests  itself  in  disturbances  of  the  autonomic  or  sympathetic 
systems. 

The  conditions  are  known  as  Vagotonia  and  Sympatheticotonia. 
Under  the  term  "Vegetative  Nervous  System"  are  included  all  those 
nerve  fibers  which  go  to  organs  having  smooth  muscles,  such  as  the  intes- 
tines, blood-vessels,  gland-ducts  and  skin  and  also  certain  cross-striated 
muscles  such  as  the  heart,  the  beginning  and  end  of  the  alimentary  canal 
and  the  muscles  of  the  genital  organs.  Excepting  the  heart,  these  muscles 
are  functionally  similar  to  smooth  muscles. 

The  autonomic  (para-sympathetic)  nerves  supply  the  glands  and  vaso- 
dilators of  the  head  and  also  enter  the  ciliary  ganglia  and  serve  definite 
functions  in  the  eyes.  The  vagus,  one  of  the  most  important  of  the 
autonomic  group,  supplies  the  heart,  bronchi,  esophagus,  stomach, 
pancreas  and  intestines;  while  the  nerves  from  the  sacral  segment,  con- 
tained in  the  pelvic  nerve,  supply  the  descending  colon,  sigmoid,  anus, 
bladder  and  genital  apparatus. 

The  vegetative  organs  are  supplied  by  nerves  both  from  the  sym- 
pathetic and  autonomic  (para-sympathetic)  systems.  Anatomically 
the  only  exceptions  are  the  sweat  glands,  pilomotor  muscles  and  vascular 
muscles  of  the  viscera  which  are  supplied  by  fibers  from  the  sympathetic 
cord.  The  sweat  glands,  though  apparently  supplied  by  the  sympathetic, 
react  to  autonomic  poisons  and  the  sympatheticotonic  adrenalin  (epine- 
phrin),  a  stimulant  of  the  sympathetic  system,  abolishes  their  secretion 
and  does  not  increase  it  as  one  would  expect. 

Pharmacological  tests  enable  us  to  differentiate  these  two  systems. 
Adrenalin  is  known  to  act  solely  upon  the  sympathetic  system  and  its 
action  is  similar  to  that  of  electrical  stimulation  of  the  sympathetic  fibers. 

1  Kraus  and  Jelliffe,  Journal  Nervous  and  Mental  Diseases,  March,  19 14,  et  al. 

892 


VAGOTONIA SYMPATHETICOTONIA  893 

Certain  drugs  exclusively  influence  the  autonomic  (para-sympathetic) 
system,  as  atropin,  pilocarpin,  physostigmin  and  muscarin.  The  last 
three  stimulate  the  autonomic  fibers,  while  atropin  prevents  many  of  the 
effects  which  would  be  caused  by  stimulation  of  these  fibers,  and  counter- 
acts to  a  certain  degree,  the  effects  produced  by  pilocarpin,  muscarin 
and  physostigmin.     The  sweat  glands  as  noted  are  an  exception. 

The  two  nervous  systems  sympathetic  and  autonomic  (para-sym- 
pathetic) are  antagonistic  in  their  action. 

The  pharmaco-dynamic  examination  of  the  functions  of  the  vegetative 
nervous  system  have  been  developed  by  Eppinger  and  Hess  for  clinical 
purposes.  They  interpreted  the  symptoms  of  some  of  these  cases,  as 
produced  by  irritability  of  the  autonomic  nervous  system.  These  patients 
responded  strongly  to  pilocarpin  and  atropin.  These  were  those  who, 
under  hypodermics  of  epinephrin  (adrenalin)  exhibit  the  phenomena 
of  stimulation  of  the  sympathetic  system,  but  who  were  not  suscep- 
tible to  the  action  of  pilocarpin  and  atropin.  These  observers  assumed 
two  systems,  of  diseases  or  dispositions,  the  vagotonic  and  the  sym- 
patheticotonic. 

It  has  been  found,  however,  that  in  some  cases  pilocarpin  and  atro- 
pin as  well  as  epinephrin  produces  strong  reactions  in  the  same  person. 

Age. — Vagotonia  particularly  occurs  more  frequently  in  youth. 

Etiology. — For  the  explanation  of  these  disturbances  of  the  vegetative 
nervous  system  numerous  causes  have  been  given.  The  neurologists 
believe  that  constitutional  inferiority  is  the  chief  factor  and  that  if  these 
patients  receive  early  proper  treatment  by  psychotherapy,  the  progressive 
development  of  vagotonia,  or  sympatheticotonia  with  resulting  finally  or- 
ganic changes  may  often  be  prevented.  Physical,  or  mental  shock,  many 
toxins  and  the  organs  of  internal  secretions  exercise  marked  influence  on 
the  vegetative  nervous  system.  The  so-called  chromaffin  (adrenalin-pro- 
ducing cells)  accompany  the  sympathetic  in  its  course,  and  adrenalin  exer- 
cises a  continuous  influence  on  the  sympathetic.  It  is  believed  probable 
that  there  is  a  physiological  "autonomin"  which  stimulates  the  autonomic 
system  though  it  is  not  as  yet  known. 

Hemmeter^  calls  to  our  attention  that  cases  of  enlarged  thyroid  occur 
where  parts  of  the  thyroid  were  found  to  be  normal,  the  symptoms  not 
being  relieved  by  thyroidectomy  and  that  undoubtedly  neuroses  of  the 
ductless  glands  may  occur  from  overexcitability  of  the  vegetative  nervous 
system,  and  their  excessive  secretion  in  turn  overstimulating  this  system, 
either  the  autonomic  or  sympathetic  portion,  produce  a  vicious  circle. 
He  holds,  therefore,  that  so-called  "organ  neuroses"  (ductless  gland  neu- 
roses) may  be  factors.  The  autonomic  and  sympathetic  systems  also  may 
be  morbidly  irritable  in  one  and  the  same  person;  hence  the  strict  division 
into  the  separate  pathological  conditions  of  vagotonia  and  sympathet- 
icotonia is  not  always  possible.  For  example  in  Basedow's  disease  one 
may  find  both  systems  in  the  same  person  may  be  overactive,  or  one  may 
predominate. 

Hemmeter  believes  that  the  patient  may  himself  concentrate  his  at- 
tention upon  some  special  organ,  in  which  there  may,  or  may  not  be  some 
'  X.  Y.  Med.  Jour.,  Jan.  17,  1914. 


894  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

disturbance,  and  in  the  latter  event  these  organs  respond  more  readily  to 
autonomic  or  sympathetic  irritation. 

Defective  development  of  the  adrenals,  with  enlarged  thymus  and  the 
lymphatic  constitution,  probably  have  a  relationship  to  the  production  of 
vagotonia.  Moreover  we  find  that  vagotonia  is  often  associated  with 
enteroptosis. 

Relation  of  Intestinal  Intoxications  to  Vagotonia. — In  conclusion  it 
is  interesting  to  observe  that  many  of  the  symptoms  associated  with  severe 
vagus  irritations  (vagotonia)  occur  in  most  cases  of  meat  or  sausage 
poisoning,  such  as  bradycardia,  low  blood  pressure,  diarrhea,  sweating, 
vomiting,  contraction  of  the  pupils,  etc.,  an  example  of  subinfection  not 
auto-intoxication.  Eppinger^  and  Guttman,  on  the  other  hand,  referring 
to  the  symptoms  of  spastic  constipation  and  its  complications,  believe  there 
is  a  close  relationship  between  general  intoxications  and  intestinal  derange- 
ments and  that  such  disturbances  are  not  limited  to  damage  to  the  in- 
testines by  poisons  introduced  from  without,  but  may  be  produced  by 
substances  originating  in  the  intestinal  tract.  For  example,  the  relief 
of  constipation  would  be  followed  by  a  disappearance  of  autonomic  irrita- 
tion with  resulting  symptoms  such  as  hyperacidity,  hypermotility,  gastric 
spasm  (pyloric),  bradycardia,  extrasystoles,  etc.  These  investigators 
turned  their  attention  to  the  intestinal  tract  to  search  for  the  hormone 
controlling  the  autonomous  system.  Barger  and  Dale  have  isolated 
from  ergotoxin  beta-imidazolylethylamin,  amido-acid  base,  apparently 
identical  with  lustidin,  a  product  of  protein  decomposition  and  of  putre- 
faction. Beta-imidazolylethylamin,  also  called  lustamin,  produces  a 
number  of  disturbances  very  similar  to  those  following  the  application  of 
poisons  which  are  known  to  be  typical  irritants  of  the  autonomous  system. 
Paraoxyphenylethylamin  another  base  was  isolated  from  ergotin.  This, 
also  named  tyramin,  is  derived  from  the  decomposition  of  ty rosin.  It  is 
said  to  possess  some  chemical  properties  similar  to  suprarenal  extract  and 
some  functional  characteristic  like  it.  Both  poisons  also  originate  during 
putrefaction.  Barger  and  Dale  have  also  isolated  lustamin  from  normal 
(not  living)  intestinal  mucosa. 

Eppinger  and  Gutman  carried  out  further  investigations  of  the 
characteristics  and  significance  of  amino-acid  bases  in  the  stools  of  normal 
and  abnormal  cases,  and  also  subsequently  isolated  the  bases  described 
by  Barger. 

They  found  a  skin  reaction  much  resembling  urticaria  occur  with 
beta-imidazolylethylamin  which  was  suggestive. 

In  animals,  lustamin  produces  symptoms  much  like  that  of  bronchial 
asthma  in  human  beings.  They  ascribe  the  origin  of  the  poisons  they 
discovered  in  the  intestinal  canal  to  bacterial  activity,  and  consider  the 
probability  that  these  bases,  originating  within  the  intestinal  canal  having 
properties  similar  to  the  hormones,  are  distributed  to  the  organism  and  exert 
their  influence  on  the  vegetative  system. 

Sjrmptoms  of  Vagotonia. — These  patients  may  be  of  either  sex  and 
young,  or  of  middle  age.  They  present  at  least  some  of  the  following 
group  of  symptoms:  Stomach  or  intestinal  disturbances;  fear  of  heart 
'  Med.  Rec,  "Intestinal  Intoxication,"  Aug.  2^9    1914. 


VAGOTONIA — SYMPATHETICOTONIA  895 

disease;  neurasthenia;  alternate  flushing  and  pallor  of  the  face,  blotchy 
areas  of  redness  on  the  arms  and  trunk;  bluish  redness  of  the  hands, 
cyanotic  and  becoming  pale  when  stroked,  cold  and  damp  to  the  feel  and 
the  palms  thickened.  Perspiration  readily  occurs  on  the  head,  face,  back 
and  feet.  Widening  of  palpebral  fissure,  so  that  the  eyes  appear  large, 
glistening  and  almost  like  exophthalmos;  constitutional  inferiority  with 
thick  nose  and  lips,  enlarged  cervical  glands,  acne  and  other  skin  eruptions; 
conjunctivae  red  or  pale,  shortsightedness,  convergent  strabismus,  no 
Moebius  sign  (i.e.,  no  weakness  in  muscular  convergence).  V.  Gaefe's 
sign  present  (formerly  considered  pathognomonic  to  Grave's  disease); 
salivation,  fissured  tongue,  arched  palate,  enlarged  uvula;  adenoids,  naso- 
pharyngeal catarrh;  pharynx  and  larynx  anesthetic  (contrast  to  irritability 
elsewhere)  so  instrumentation  is  easy.  Voice  is  hoarse,  respirations  shallow 
and  diminished  in  frequency;  bradycardia  or  Erben's  phenomenon 
(transition  from  tachycardia  to  bradycardia  when  kneeling),  arrhythmias, 
respiratory  changes  in  the  pulse,  sticking  of  food  in  the  esophagus,  fulness, 
distention,  acid  retching,  heart  burn,  appetite  usually  good;  bowels  fre- 
quently sluggish,  stools  few  with  diminished  bulk  though  diarrhea  occurs; 
sigmoid  distended  with  feces;  mild  anginoid  attacks  or  laryngismus  or 
bronchial  asthma,  urine  in  small  amounts,  acid,  and  highly  colored. 

Stigmata  of  Vagotonia. — Among  these  are  dermography,  the  Aschner 
reflex  (pressure  on  eyeball  produces  bradycardia);  Erben's  phenomenon 
(bradycardia  on  kneeling  when  pulse  was  previously  rapid) ;  Chovostek's 
sign  (increase  in  mechanical  excitability  of  the  motor  nerves,  as  a  tap  over 
the  facial  causes  constriction  of  muscles  supplied  by  it),  tremors  of  lids, 
increased  tendon  reflexes  and  activity  of  cremasteric  and  abdominal  muscle 
reflexes;  as  a  further  test  atropin  markedly  affects  the  eyes  and  yet  ameli- 
orates symptoms,  while  after  pilocarpin  injections  the  stomach  contracts, 
hyperacidity  occurs,  also  stool  takes  form  as  found  with  spastic  constipa- 
tion, there  are  eosinophilia  and  symptoms  resembling  pylorospasm, 
cardiospasm,  asthma,  hypersecretion,  gall-stone,  colic,  etc.,  from  which 
Eppinger  attributes  to  vagotonia.  Gastro-intestinal  symptoms  as  follows: 
rumbling  and  pains  after  eating,  increased  peristalsis  demonstrated  by 
aj-rays,  spasmodic  hour-glass  contraction,  cardiospasm,  pyloric  spasm, 
hyperacidity,  hypersecretion,  hyperesthesia,  gastric  ulcer  (from  local 
spasm  with  hyperacidity),  spasm  affecting  the  gall-bladder,  nervous 
diarrheas  ('  'neurogenic").  Some  of  diarrheas  in  Basedow's  disease  belong 
to  vagotonia  and  possibly  with  tuberculosis,  leukemia  and  lympho-sarcoma 
(Eppinger);  acid  jejunal  diarrhea,  mucous  colitis;  eosinophilic  catarrh 
(mucous  catarrh  plus  eosinophilia);  spastic  catarrh,  hypermobility  with 
diarrhea ;  spastic  constipation  and  spasm  of  the  sphincter  ani.  Enteroptosis 
often  occurs  in  association  with  vagotonia  or  sympatheticotonia  or  irrita- 
bility of  both  systems.  A  polyneuritis  affecting  the  occipital,  trigeminus 
intercostal  and  nerves  of  the  arms  and  back,  also  the  crural  and  sciatic 
nerves  has  been  described  by  von  Noorden.  The  pains  are  wandering 
in  character  and  there  may  be  tender  points  in  their  course.  The  pains 
may  affect  the  muscles  or  even  the  joints  but  there  are  no  swelling  or 
redness  and  pains  occur  early  in  the  morning  ^on  first  movements  and 
later  disappear.     In  association    there    are    marked   indicanuria   hyper- 


896  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

acidity,  retention  of  feces  in  the  sigmoid  with  a  sensitive  point  (S.  point) 
over  it,  level  of  McBurney's  point;  on  the  left  side,  however;  occasionally 
diarrhea,  urticaria,  dermography  and  other  symptoms  of  vagotonia. 
There  is  slight  temperature.  This  polyneuritis  is  believed  to  be  due  to 
intestinal  toxemia  (putrefaction). 

Symptoms  of  Sympatheticotonia. — There  may  be  mydriasis,  tachy- 
cardia, constriction  of  the  vessels  with  resulting  cold  hands  and  feet, 
mottling  or  a  red  nose,  hyperesthesia,  great  susceptibility  to  temperature 
changes,  numbness,  sensation  of  pins  and  needles,  deficiency  of  perspira- 
tion, gooseflesh,  perverse  skin  reaction  (a  condition  of  pallor  in  response 
to  shock),  intermittent  pulse,  transitory  attacks  of  high  blood  pressure, 
pulsation  of  abdominal  aorta,  transitory  vertigo,  nasal  hemorrhage  or 
catarrh,  hemorrhoids,  increased  climacteric  disturbances.  Among  the 
gastro-intestinal  disturbances  are  dry  mouth  (dimunition  of  saliva), 
increased  gag  reflex,  though  tube  can  readily  be  passed  on  account  of 
relaxed  esophagus;  cardia  relaxed  so  regurgitation  occurs;  atony  of  the 
stomach  with  delayed  emptying,  or  atonic  dilatation;  splashing  sound 
readily  produced;  hydrochloric  acid  diminished;  pancreatic  secretion 
lessened,  motility  and  secretory  activity  of  intestines  diminished,  atonic 
constipation.  Hence  gastro-intestinal  functions  are  diminished  in  their 
activity. 

It  will  be  readily  seen  that  vagotonia  or  sympatheticotonia,  singly 
or  together  in  alternation,  may  explain  many  of  our  so-called  gastro- 
intestinal neuroses. 

Treatment. — Psychotherapy  would  be  of  value  in  the  early  stages,  in 
order  to  divert  attention  from  the  particular  organ  complained  of  by  the 
patient.  With  the  vagotonics  atropin  and  adrenalin  have  proved  of 
service,  atropin  being  of  particular  value  in  reducing  spasm  and  dimin- 
ishing secretion  atropin  gr.  J^oo  to  >^o  t.i.d.,  sometimes  the  dosage 
must  be  pushed  higher.  Occasionally  tinct.  belladonna  gtts.  x,  three  or 
four  times  daily  or  ext.  belladonna  gr.  }4  t.i.d.  may  be  substituted.  Adren- 
alin chloride  (i  :  1000)  10  to  15  drops  by  hypodermic  acts  in  these  cases  by 
stimulating  the  sympathetic.  Three  or  four  doses  may  be  used  daily, 
particularly  valuable  in  asthma. 

In  cases  of  sympatheticotonia  pilocarpin  gr.  }{q  t.i.d.  to  increase 
gastric  or  pancreatic  secretion,  or  physostigmin  gr.  J^oo  to  }4o  t.i.d.  for 
intestinal  atony,  for  example.  Enteroptosis,  chronic  intestinal  putrefac- 
tion and  other  special  conditions  should  be  treated  appropriately.  In 
conclusion  the  writer  wishes  to  express  his  appreciation  to  Smith  Ely 
Jelliffe  for  much  valuable  material  in  his  description  of  these  conditions. 

VISCERAL  CRISES  IN  THE  ERYTHEMA  GROUP 

In  the  study  of  these  conditions  one  notes  that  they  merely  describe 
another  phase  of  instability  of  the  vegetative  nervous  system  and  may 
really  be  classified  under  Vagotonia  and  Sympatheticotonia. 

Under  "Differential  Diagnosis  in  Appendicitis"  the  writer  refers  to 
various  types  of  erythenaa,  urticaria,  angioneurotic  edema  and  Henoch's 
purpura  producing  visceral  lesions  with  symptoms,  simulating  appendicitis. 


VAGOTONIA — SYMPATHETICOTONIA  897 

In  addition  nausea,  vomiting,  diarrhea  and  hemorrhages  from  the  mucous 
membranes,  melena,  etc.,  may  occur.  The  attacks  have  also  been 
mistaken  for  intussusception  and  when  operated  upon  there  has  been 
found  an  acute  sero-hemorrhagic  infiltration  of  a  limited  area  of  the 
stomach  or  intestine,  resembling  angioneurotic  edema.  Enlargement  of 
the  spleen  is  usually  present  in  these  cases  and  albuminuria  and  acute 
nephritis  may  occur  and  prove  a  serious  complication. 

Osler^  classifies  the  group  as  follows:  Cases  of  pure  angioneurotic 
edema,"  cases  in  which  urticaria  is  the  associated  skin  lesion;  Henoch's 
purpura  with  arthrites,  purpura  or  erythema  and  colic ;  cases  with  ery- 
thema multiforme,  with  or  without  edema  and  frequently  with  redness  or 
purpura;  cases  with  recurrent  colic,  and  nothing  else  determinable,  it 
may  recur  some  years  before  the  skin  lesion  appears. 

Etiology. — Members  of  certain  families  are  predisposed  to  these  con- 
ditions and  Osier  has  traced  heredity  to  angioneurotic  edema  through 
five  generations.  Attacks  recur  and  one  can  frequently  find  in  the  history, 
evidences  of  instability  of  the  vasomotor  mechanism  or  as  Solis-Cohen 
terms  it  "vasomotor  ataxia"  such  as  dermographia,  transient  skin  erup- 
tions, asthmatic  attacks,  hay-fever,  arthritic  attacks,  repeated  hemor- 
rhages from  apparently  unknown  causes,  hysteria,  hyperidrosis,  drug 
idiosyncrasies,  migraine,  vertigo,  visual  disturbances,  polyuria,  etc.  The 
exciting  cause  of  the  attack  may  be  from  cold  or  emotion  and  in  many 
cases  from  the  gastro-intestinal  tract.  Thus  some  have  an  idiosyncrasy 
to  strawberries  and  shellfish.  Undoubtedly  in  many  of  these  cases  an 
idiosyncrasy  to  protein  absorption,  with  parenteral  digestion  with  toxin 
elimination  (anaphylaxis),  is  responsible. 

Symptoms. — The  description  of  these  cases  would  place  them  chiefly 
under  vagotonia  with  occasionally  symptoms  of  sympatheticotonia.  They 
usually  show  an  unstable  vasomotor  system  and  suffer  from  dermographia, 
skin  mottling,  rapid  or  irregular  heart  action,  or  palpitation  or  intermit- 
tent tachycardia  or  functional  murmurs  may  be  present.  In  some  cases 
there  may  be  tremulousness  of  the  lids,  widening  of  the  commissure  of 
the  eyelids,  and  dilatation  of  the  pupils  which  react  to  light,  but  with  wide 
oscillation.  The  character  of  the  eruption  may  vary;  thus  purpura, 
at  times  measles  may  be  simulated,  or  there  may  be  erythema  with  urti- 
caria, or  nodules  with  dark  centers.  The  eruptions,  however,  are  rather 
constant  in  their  distribution  over  the  extensor  surfaces  of  the  hips,  knees, 
ankles  and  elbows.  Angioneurotic  edema  may  be  limited  in  extent. 
Some  cases  show  only  recurring  attacks  of  colic  and  no  skin  eruption  for 
several  years.  The  colic  attacks  often  come  at  intervals  of  a  month  or  so, 
and  tend  to  recur.  A  chill  may  accompany  the  attack.  The  pain  is 
extremely  severe,  in  some  cases  beginning  in  the  epigastrium  and  becom- 
ing diffuse,  while  in  others  it  may  be  confined  to  the  lower  segment  of  the 
abdomen.  Some  resemble  biliary  or  renal  colic,  though  radiation  of 
of  the  pain  is  not  common.  Nausea,  vomiting  of  food,  or  clear  or  greenish 
or  bloody  fluid,  together  with  diarrhea  with  melena,  preceded  by  constipa- 
tion, quite  often  accompany  the  colic  attack.  The  patient  may  appear 
quite  ill.  There  may  be  rigidity  and  tenderness  over  the  colon,  appendix, 
1  Johns  Hopkins  Hosp.  Bull.,  vol.  xv,  p.  260. 
57 


898  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

in  the  epigastric  region,  or  in  all  three.  The  writer^  has  already  referred 
to  a  case  of  acidosis  and  indicanuria  from  dietetic  indiscretions  with  an 
erythematous  eruption  and  angioneurotic  edema  of  the  ascending  colon 
and  cecum  simulating  appendicitis.  The  abdomen  is  often  decidedly 
retracted  and  distention  is  rare.  At  times  a  mass  can  be  felt  which  opera- 
tion during  the  crisis  has  demonstrated  to  be  a  swollen  portion  of  the 
intestine,  operation  having  been  performed  through  mistake  in  diagnosis. 

The  intestinal  wall  for  several  inches  in  some  of  these  cases  was  swollen 
and  edematous,  the  last  part  of  the  ileum  being  most  frequently  involved, 
the  peritoneal  coat  congested  and  studded  with  petechiae  and  ecchymotic 
areas.  A  small  amount  of  fluid  was  found  in  the  peritoneal  cavity.  It 
was  clear  in  some  cases  and  turbid  or  bloody  in  others. 

One  operator  reports  a  case  in  which  the  intestines  were  pale  and  in 
spasmodic  contraction. 

The  abdomen  has  been  opened  between  attacks  and  the  organs 
appeared  normal. 

The  spleen  is  quite  frequently  moderately  enlarged ;  usually  a  moderate 
leukocytosis  14,000  or  thereabouts  is  present.  With  hemorrhagic  cases 
coagulation  time  is  slow. 

Albuminuria  with  blood  and  casts,  hemorrhage  into  the  mucous 
membranes  and  retina  and  arthritis  may  occur.  Severe  acute  nephritis 
may  cause  a  fatal  termination  and  there  may  be  no  edema  with  it.  Pleu- 
risy, pericarditis,  endocarditis  and  pneumonia  may  complicate.  In- 
tussusception and  perforation  of  the  fundus  of  the  stomach  (from  necrotic 
foci  from  purpura)  have  been  reported. 

Other  crises  such  as  hemiplegia,  monoplegia,  asphasia,  swelling  of  the 
fauces  and  pharynx,  edema  of  the  glottis  and  asthma  may  occur. 

Diagnosis. — One  must  exclude  erythemas  secondary  to  organic  diseases 
such  as  cardiac  disease,  liver  cirrhosis,  cholelithiasis,  nephritis,  etc. 

The  family  and  personal  history  with  physical  examinations  generally 
give  us  the  required  information.  In  the  colic  cases  with  no  eruption,  the 
diagnosis  is  more  difficult. 

In  the  cases  simulating  appendicitis — abdominal  retraction  is  more 
often  present,  while  with  appendicitis  there  is  more  often  distention. 
Tenderness  and  rigidity  are  more  marked  with  appendicitis  and  melena 
occurs  quite  frequently  with  the  visceral  crises. 

Treatment. — Arsenic  and  iron  are  of  value  to  prove  the  general  con- 
dition of  these  cases.  Idiosyncrasies  as  to  certain  foods  should  be 
investigated. 

Monobromate  of  camphor  can  also  be  employed.  Atropin  or  adrena- 
lin are  indicated  for  the  vagotonia,  and  the  usual  treatment  of  sym- 
patheticotonia  if  such  is  present.  In  cases  from  protein  absorption, 
hexamethylin  gr.  5  to  10  t.i.d.  abolition  of  the  objectionable  proteid  and 
correction  of  the  gastro-intestinal  functions  and  of  the  chronic  intestinal 
putrefaction  are  indicated.  Sour  milks  are  of  service.  In  hemorrhagic 
cases  lactate  calcium  gr.  x,  fobr  to  six  times  daily  with  10  per  cent,  gelatin, 
or  horse  serum  by  mouth  or  human  serum  by  hypodermic  or  direct  infusion 
are  indicated.  Rest  in  bed  and  milk  diet  are  useful  for  the  nephritis. 
^  Amer.  Jour.  Med.  Sci.,  February,   1894,  cvii,  145. 


VAGOTONIA — SYMPATHETICOTONIA  899 

UMBILICAL  DYSPEPSIA 

Aaron^  reports  a  condition  which  he  denominates  umbilical  dyspepsia 
resulting  from  a  congenital  defect  in  the  abdominal  parietes  preventing 
closure  of  the  umbilical  canal.  The  defect  is  at  the  opening  for  the 
omphalomesenteric  duct  and  the  urachus.  It  is  not  a  true  umbilical 
hernia.     The  opening  may  be  so  small  at  first  as  to  escape  notice. 

Sjnnptoms. — There  are  symptoms  of  nervous  dyspepsia  due  to  in- 
creased irritability  of  the  autonomic  nervous  system.  Symptoms  may  be 
absent  for  days  and  then  recur  from  some  trivial  cause.  Appetite  is 
capricious;  at  times  coarse  food  may  be  taken  with  impunity,  while  an 
ordinary  diet  may  be  rejected.  There  are  fulness  of  the  head,  headache, 
inability  to  work,  vertigo,  depression  and  lassitude.  There  may  be 
heaviness  immediately  after  eating,  or  uneasy  sensations  one  to  two  hours 
later.  The  discomfort  does  not  depend  on  the  quantity  or  quality  of 
food.  Constipation  is  usually  present  and  the  nutrition  generally  good. 
If  the  subjective  symptoms  become  severe,  loss  of  weight  results  from 
refusal  to  take  sufficient  nourishment. 

Physical  Examination. — Deep  palpation  with  the  fingers  over  the 
umbilicus  elicits  severe  pain.  It  may  radiate,  or  be  referred  to  a  distant 
part  of  the  abdomen.  When  pressure  ceases,  the  pain  stops.  In  more 
advanced  cases  the  separation  at  the  umbilicus  can  be  determined. 

The  stomach  may  possess  normal  functions  but  hyperacidity  is  more 
usually  present. 

Treatment. — Bring  the  edges  of  the  congenital  opening  as  closely  to- 
gether as  possible  with  adhesive  strapping— preferably  a  strip  2  inches  wide 
and  long  enough  to  extend  2^  to  4  inches  on  either  side  of  the  umbilical 
opening.  Cleanse  the  abdomen  first  with  soap,  water  and  alcohol,  and 
clean  the  umbilicus.  Hair  should  be  shaved  off.  The  treatment  should 
be  continued  from  4  to  10  weeks.  Ether  or  oil  of  wintergreen  aid  in 
removal  of  plaster.  Elastic  abdominal  support  is  a  useful  adjunct. 
Treat  the  hyperacidity  if  present  by  appropriate  remedies,  and  vagotonia 
by  belladonna  or  atropin.  The  bromids  are  useful.  Stomachics  may  be 
required.  Nourishing  food  should  be  administered,  such  as  butter,  cream, 
milk,  eggs,  etc. 

It  would  seem  to  the  author  that  surgical  procedure  might  in  some 
cases  be  necessary. 

*Jour.  A.  M.  A.,  May  13,  1916. 


CHAPTER  XXXV 
NERVOUS  DISEASES  OF  THE  INTESTINES 

Under  this  heading  are  included  those  conditions  due  to  perversion 
of  the  innervation  of  the  intestines  independent  of  anatomic  lesions  of 
the  intestinal  wall  or  of  distant  organs. 

In  many  cases  the  neurotic  manifestations  in  the  intestines  are  an  in- 
dependent manifestation  of  some  general  neurosis,  such  as  of  neurasthenia, 
hysteria,  or  hypochondriasis.  Some  few  cases  result,  purely  from  func- 
tional perversion  of  the  intestinal  nerves.  Vagotonia  and  sympathetico- 
tonia  may  explain  some  of  these  conditions. 

Intestinal  neuroses  may  be  divided  into  motor,  sensory,  and  secretory. 
They  often  exist  in  combination.  Psychic  influences,  such  as  fear,  fright, 
worry,  and  anxiety,  may  be  causes,  as  may  reflexes  from  some  diseased 
organs,  such  as  the  stomach  or  genito-urinary  tract. 

The  nerve-centers  influencing  peristalsis,  Meissner's  and  Auerbach's 
plexuses,  have  been  described  in  the  chapter  on  Physiology  of  Digestion, 
Part  I,  under  Nervous  Control  of  Peristalsis. 

Secretion  seems  to  be  dependent  to  a  great  extent  upon  the  ganglionic 
plexus.  Moreau^  ligated  an  intestinal  coil  and  severed  all  the  nerves 
passing  to  it.  In  a  few  hours  it  was  filled  with  fluid,  showing  amylolytic 
qualities  and  containing  albumin. 

After  ingestion  of  food  into  the  stomach,  secretion  takes  place  in  the 
lower  part  of  the  intestines  before  the  arrival  of  the  chyme.  This  was 
demonstrated  by  Quincke  and  Demant. 

Vasomotor  filaments  exist  in  the  intestines  as  stimulation  of  the 
splanchnic  causes  contraction,  and  its  section  causes  dilatation  of  the 
intestinal  blood-vessels.     They  are  also  concerned  with  absorption. 

Sensory  filaments  exist  in  the  intestines,  since  stimuli  of  greater  in- 
tensity than  normal,  such  as  the  ingestion  of  beans  or  cabbage,  may  give 
rise  to  sensations  of  pain  or  pressure.  Kast  and  Meltzer^  have  demon- 
strated experimentally  that  the  sensation  of  pain  exists  in  the  intestines, 
and  that  laparotomy,  under  cocain,  causes  anesthesia  of  the  intestines 
through  the  cocain  being  carried  by  the  blood. 

MOTOR  NEUROSES  OF  THE  INTESTINES 

Peristaltic  Unrest  (Tonnina  Intestmorum). — This  condition  consists 
in  marked  rotary  or  rolling  movements  of  the  intestines,  so  that  they 
frequently  become  visible.  It  is  usually  seen  in  patients  with  hysteria 
or  hypochondriasis.  Occasionally  it  is  an  independent  affection.  It 
is  almost  exclusively  seen  in  the  small  intestine. 

1  Centralbl.  fur  die  Med.  Wissensch.  i86,  No.  14. 
?  Med.  Rec,  Dec.  29,  1906. 
9qp 


NERVOUS   DISEASES    OF    THE   INTESTINES  9OI 

Peristaltic  restlessness,  which  accompanies  complete  or  incomplete 
occlusion  of  the  intestines,  is  not  included  herein.  There  is  not  the 
peculiar  stiffening  of  the  intestinal  coils,  as  is  present  with  stenosis,  and 
other  symptoms  of  that  condition  are  absent.  Occasionally  the  condi- 
tion occurs  in  persons  presenting  no  other  nervous  symptoms,  as  after 
the  ingestion  of  highly  spiced  or  indigestible  foods,  after  the  excessive  use 
of  tobacco,  mental  excitement,  or  too  much  brain  work. 

CHnically,  there  are  rolling,  gurgling,  squelching  noises  in  the  abdomen 
of  varying  intensity.  They  can  often  be  heard  at  some  distance  and  are  a 
source  of  mortification  to  the  patient.  Pain,  as  a  rule,  is  not  present. 
The  movements  of  the  intestines  may  occasionally  become  visible  and 
palpable.  Eructations  sometimes  occur  when  peristaltic  unrest  of  the 
stomach  is  associated. 

Attacks  occur  at  irregular  intervals  and  may  take  place  during 
menstruation. 

Diagnosis. — Stenosis  of  the  bowel  must  be  excluded.  The  nervous 
t)^e  of  peristaltic  restlessness  of  the  intestines  is  readily  recognized. 
Prognosis  is  favorable. 

Treatment. — This  should  be  directed  toward  the  tone  of  the  nervous 
system.  Heat  externally  applied  and  the  drinking  of  hot  water  during 
the  attack  are  of  value.  Spicy  and  indigestible  food  should  be  excluded. 
Priessnitz  compresses  should  be  applied  to  the  abdomen  at  night.  The 
bromids,  valerian,  and  asafetida  are  useful.  Arsenic  alone  or  combined 
with  iron  should  be  employed  in  anemia.  If  there  is  any  disturbance 
of  the  bowels  (diarrhea  or  constipation)  it  should  be  properly  regulated. 
Rarely  a  small  dose  of  opiate,  alone  or  combined  with  belladonna,  is 
required.  If  the  attacks  occur  at  night,  chloral  hydrate,  15  grains  (i.o) 
or  veronal,  7^^  grains  (0.5),  sulphonal  or  trional,  10  grains  (0.6),  may  be 
necessary.  Electricity  and  massage  have  been  recommended.  Change 
of  climate  is  beneficial. 

Nervous  Diarrhea. — These  exaggerated  peristaltic  movements  occur 
not  only  in  the  small,  but  also  in  the  large  intestine.  They  may  be  limited 
to  the  colon  in  some  cases.  There  is  an  increased  transudation  of  fluid 
due  to  nervous  influences.  The  reader  should  refer  to  a  description  of  this 
condition  under  Diarrhea.  Spastic  constipation,  due  to  local  enterospasm 
and  also  spasm  of  the  sphincter,  sometimes  occurs  in  neuropathic,  hypo- 
chondriac, or  hysteric  subjects.  These  conditions  are  described  under 
Constipation. 

Paralysis  of  the  Intestines. — Paralysis  resulting  from  a  mechanical 
obstacle  to  the  passage  of  the  intestinal  contents  has  been  described. 
Primary  paralysis  of  the  intestines  without  any  organic  obstacle  will 
itself  cause  symptoms  of  obstruction.  The  reader  is  further  referred 
to  Dynamic  Ileus. 

There  are  several  forms  of  this  condition:  i.  An  intestinal  coil 
may  become  paralyzed  after  forced  reposition  of  a  hernia  or  after  incar- 
ceration; it  may  be  due  to  direct  traumatism,  to  abdominal  operation,  or 
to  inflammation  or  ulcerative  processes  of  the  intestines. 

2.  It  may  result  from  reflex  irritation. of  the  inhibitory  nerves  of  the 


902  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

muscular  coats  of  the  intestines,  especially  where  there  is  injury  or 
inflammation  which  does  not  necessarily  involve  the  bowel. 

Toxemia  may  be  a  factor.  Contusion  of  the  testicles,  abdominal 
abscess,  anesthesia,  uremia,  etc.,  are  causes. 

3.  Neuroses,  melancholia,  hypochondria,  or  affections  of  the  nervous 
system,  such  as  meningitis,  brain  tumors,  tabes,  myelitis,  etc.,  are  also 
causes.  Atony  of  the  intestines,  leading  to  coprostasis,  has  been  sug- 
gested as  a  cause  of  intestinal  paralysis.  It  would  seem  that  the  symp- 
toms are  produced  by  occlusion.  Intestinal  atony  is  really  a  subparetic 
condition,  and  the  nervous  type  is  described  under  Chronic  Constipation. 

Meteorism  in  hysteria  is  probably  due  to  sudden  paresis  of  the  muscular 
coat  of  the  bowel.     See  Meteorism. 

Treatment. — Removal  of  fecal  impaction  by  the  fingers  if  present, 
enemata  of  soapsuds,  i  quart  (liter),  containing  olive  oil,  8  ounces  (250 
c.c),  and  glycerin,  i  ounce  (30.0),  electric  enteroclysis,  enteroclysis,  simple 
enemata,  massage,  and  electricity  are  useful.  With  fecal  impaction,  liquid 
mercury,  10  to  20  ounces  (300.0-600.0),  given  through  a  stomach-tube, 
is  of  value.  It  might  otherwise  enter  the  larynx.  Various  cathartics, 
such  as  castor  oil,  i  to  2  ounces  (30.0-60.0);  olive  oil,^4  ounces  (128.0); 
physostigmin  sulphate,  ^00  to  3^0  grain  (0.0006-0.001),  may  be  em- 
ployed. Lavage,  followed  by  the  administration  of  the  cathartic  through 
the  stomach-tube,  is  useful. 

For  further  treatment,  the  methods  pursued  in  Dynamic  Ileus  should 
be  consulted. 

Paralysis  of  the  Sphincters. — It  occurs  as  one  of  the  symptoms  of 
rectal  affections.  Tenesmus  may  lead  to  exhaustion.  Ulceration  and 
infiltration  of  the  rectum  at  times  involve  the  sphincters,  interfering  with 
their  function  or  destroying  it. 

Improper  methods  of  operations  on  the  rectum  may  cause  paralysis. 
Accumulation  of  feces  may  impair  the  tone  of  the  muscles.  Diseases 
of  the  brain  and  spinal  cord  may  cause  paralysis  of  the  sphincters.  It 
may  be  a  pure  neurosis. 

Some  patients  are  not  able  to  keep  the  rectum  tightly  closed  and  a 
small  amount  of  discharge  continually  escapes.  In  others  involuntary 
movements  occur  after  excitement,  exertion,  or  during  urination,  there 
being  only  a  partial  paresis.  With  complete  paralysis,  flatus  and  feces 
escape  involuntarily,  even  when  resting. 

With  paralysis  resulting  from  proctitis,  hemorrhoids,  stricture,  etc., 
there  is  a  continuous  dripping  of  mucous  secretion  which  irritates  the  skin. 

Diagnosis. — The  anus  appears  patulous  and  several  fingers  can  be 
introduced  into  the  rectum  without  resistance.  To  diagnose  purely 
nervous  paralysis,  anatomic  lesions  must  be  excluded  by  means  of  examination 
withti  speculum. 

Prognosis. — This  depends  upon  the  cause — in  the  pure  neuroses  it 
is  favorable. 

Treatment. — Thorough  evacuation  of  the  bowels,  preferably  by 
enemata  twice  daily,  is  important.  The  addition  of  alum,  i  dram  to 
I  pint  (4.0-500  c.c.)  of  water  by  enema,  is  useful.     If  due  to  nervous  con- 

^  Large  doses  of  olive  oil,  3  vi-viii,  and  mineral  oil,  3  ii-iv,  through  a  duodenal  tube 
are  useful. 


NERVOUS    DISEASES    OF    THE   INTESTINES  903 

ditions,  electricity  and  massage,  especially  local  vibrations,  as  suggested 
by  the  late  J.  P.  Tuttle,  are  beneficial.  Tonics,  such  as  iron  and  arsenic, 
are  useful.  Strychnin,  ^q  to  y^o  grain  (0.001-0.0015)  by  hypodermic 
into  the  anal  folds,  has  been  recommended  by  Rosenheim.  General 
improvement  of  the  nervous  system  and  at  times  change  of  scene  are 
indicated. 

Occasionally  difl&culty  in  urination  and  straining  may  cause  paresis 
of  the  sphincter.     Catheterization  will  improve  this  condition. 

In  the  cases  in  which  the  nervous  condition  is  not  responsible,  but 
some  anatomic  lesion,  appropriate  treatment  is  indicated. 

SENSORY  NEUROSIS  OF  THE  INTESTINES 

I  agree  with  Riegel  that  true  colic  is  not  a  sensory  neurosis.  I 
have  called  attention  to  the  fact  that  the  pain  of  colic  is  produced  by 
tetanic  contractions  of  the  intestinal  muscles,  and  that  it  is  a  secondary 
symptom. 

Hjrperesthesia  of  the  Intestines. — Under  normal  conditions  digestion 
is  carried  on  without  producing  any  sensation  whatever.  In  cases  of 
neurasthenia,  hysteria,  and  hypochondriasis  the  patient  may  be  conscious 
of  abnormal  sensations  in  the  intestines  after  the  ingestion  of  food.  They 
may  occasionally  appear  after  violent  emotion  or  shock.  These  sensations 
consist  in  a  feeling  of  fulness,  stabbing,  burning,  tearing,  and  as  if  the 
ingesta  were  moving  about  in  the  abdomen.  Occasionally  delusions  may 
develop.  In  some  there  is  local  hyperesthesia,  especially  in  the  rectum. 
There  is  a  feeling  of  tenesmus  or  fulness,  as  if  some  foreign  material  were 
impacted  therein,  though  the  rectum  is  normal  and  contains  no  fecal 
matter.  In  others,  pressure  and  weakness  occur  in  this  region,  or  there  is 
burning,  tickling,  itching,  stabbing,  or  a  cutting  feeling,  at  times  combined 
with  voluptuous  sensations. 

Anesthesia  of  the  Rectum. — In  these  patients  the  desire  for  defecation 
is  absent.  In  pronounced  cases  movement  may  occur  without  being  felt. 
Such  conditions  are  met  with  only  in  patients  with  spinal  and  brain 
trouble,  or  in  the  old  and  decrepit.  Paralysis  of  the  sphincters  may 
occasionally  accompany  this  condition. 

Treatment. — This  must  be  directed  toward  the  improvement  of  the 
nervous  condition.  Change  of  climate  and  hydrotherapy  are  valuable. 
Highly  spiced  food,  alcohol,  and  red  meats  should  be  forbidden. 

Abnormal  sensations  in  the  rectum  may  be  improved  by  cold  rectal 
douches,  sitz-baths,  the  cold  prostatic  cooler,  such  as  I  advocated  in  the 
treament  of  hemorrhoids,  and  by  rectal  galvanization. 

With  rectal  anesthesia  cleansing  enemata  are  useful.  It  may  be 
necessary  to  wear  a  rectal  obturator  (Fig.  363)  to  prevent  soiling. 

Nervous  Enteralgia  (Neuralgia  Mesenterica). — Aside  from  enteralgia 
due  to  irritating  factors,  it  may  result  from  a  perverted  state  of  the 
sensory  intestinal  nerves.  This  condition  is  not  due  to  spasm  of  the 
intestinal  muscles,  like  colic,  but  to  a  neuralgic  affection  of  the  bowels. 
It  appears  as  a  primary  affection  and  is  found  in  patients  troubled  with 
hysteria,  neurasthenia,  or  spinal  difficulty.     It  may  occasionally  be  reflex, 


904  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

from  abnormal  conditions  of  the  kidneys,  bladder,  uterus,  ovaries,  and 
liver.  It  may  occur  as  a  neuralgic  condition  even  after  the  removal  of 
some  primary  cause  in  the  intestines.  The  first  symptom  is  pain,  which 
usually  begins  in  the  umbilical  region,  mild  at  first,  but  gradually  increas- 
ing in  intensity.  It  may  radiate  in  various  directions.  Pressure  over  the 
abdomen  and  the  passage  of  flatus  usually  relieve  the  pain.  It  may  be  of 
a  cutting  or  stabbing  type,  and  may  even  produce  shock  or  syncope. 
The  bowels  may  be  nearly  normal  or  constipated.  Appetite  and  digestion 
may  be  good.     Palpitation,  dyspnea,  strangury,  etc.,  may  occur. 

Neuralgic  attacks  can  occur  in  lead-poisoning  without  the  true  spasm. 
Hemmeter  has  reported  three  cases  of  gouty  neuralgia  of  the  intestines. 
Romberg  holds  that  the  abnormal  crisis  of  tabes  dorsalis  is  due  to  nervous 
enteralgia.  Examination  of  the  symptoms  demonstrates  that  true  colic 
is  present.  The  Romberg  symptom,  Argyll-Robertson  pupil,  and  absence 
of  patellar  reflexes  are  diagnostic  of  syphilis,  also  the  presence  of  the 
Wassermann  reaction. 


Fig.  363. — Rectal  obturator. 

Hypogastric  Neuralgia  (Romberg). — In  some  cases  of  tabes  there  is  a 
purely  local  form  of  neuralgia,  limited  to  the  rectum.  The  attacks  are 
characterized  by  violent  tenesmus,  paroxysms  of  pain,  a  feeling  as  if  a 
red-hot  iron  were  inserted  in  the  rectum,  and  occasionally  diarrhea.  This 
condition  is  also  frequently  found  in  diabetes  and  in  women  having  uterine 
trouble,  piles,  or  who  are  neurasthenic. 

The  picture  presented  by  nervous  enteralgia,  on  the  other  hand,  as 
Riegel  remarks,  may  occupy  an  intermediate  position  between  peritonitis 
and  colic  pseudoperitonitis.  Violent  attacks  of  pain  occur  in  the  abdomen 
at  short  intervals.  Associated  with  this  is  frequently  pronounced  collapse, 
wich  great  abdominal  tenderness*  on  light  pressure.  Vomiting,  which  is 
usually  present  in  peritonitis,  is  always  absent  in  these  cases.  The  skin 
of  the  abdomen  is  generally  hyperalgesic.  The  functions  of  the  intestines 
and  stomach  between  attacks  are  undisturbed,  and  the  patients  feel 
perfectly  well. 

Treatment. — This  should  be  directed  toward  improvement  of  the 
hysteria  and  neurasthenia.  Change  of  climate,  hydrotherapy,  massage, 
electricity,  and  moral  treatment  are  of  service.  Arsenic  is  valuable. 
The  bowels  should  be  kept  regular  and  a  simple  diet  advised. 

^  There  is  no  true  tenderness  on  deep  pressure,  and  muscular  rigidity  is  absent. 


NERVOUS    DISEASES    OF    THE   INTESTINES  905 

With  neuralgia  hypogastrica,  if  there  is  local  disturbance,  this  should 
be  treated.  Warm  sitz-baths  and  hot  enemata  are  useful.  Occasionally 
an  opium-and-belladonna  suppository  may  be  required.  Tabes  should 
receive  treatment. 

SECRETORY  NEUROSES  OF  THE  INTESTINES 

Though  secretion. in  the  intestines  immediately  follows  the  entrance  of 
food  into  the  stomach,  thus  demonstrating  the  presence  of  secretory  nerves 
in  the  intestines,  we  still  have  little  knowledge  of  the  subject. 

Nervous  diarrhea,  which  has  been  described  as  a  motor  neurosis,  is 
often  accompanied  by  art  increased  flow  of  intestinal  juice.  Increased 
intestinal  secretion  is  found  in  membranous  enteritis,  though  I  do  not 
consider  this  disease  a  pure  neurosis  of  secretion. 

INTESTINAL  NEURASTHENIA 

Combinations  of  the  intestinal  neuroses  frequently  occur.  Rosen- 
heim designates  such  cases  as  intestinal  neurasthenia.  The  appetite 
is  good  and  the  symptoms  usually  appear  when  intestinal  digestion  takes 
place — about  two  to  three  hours  after  meals. 

There  are  pressure,  tension,  and  griping  in  the  abdomen.  Occasionally 
there  is  nausea,  and  at  times  an  evacuation  of  the  bowels  occurs  accom- 
panied with  painful  sensations  in  the  abdomen  and  anus.  Palpitation 
occurs  at  times;  sometimes  flashes  of  heat  or  cold.  Generally  the  patient 
feels  worse  when  resting  in  the  recumbent  position  than  when  walking 
about.  The  symptoms  usually  disappear  in  a  couple  of  hours  to  return 
later  after  a  meal.     Constipation  usually  is  present. 

The  quality  of  the  food  does  not  exert  any  influence  on  tlw  symptoms^ 
Borborygmi  and  diarrhea  occasionally  are  present,  and  the  latter  in  the 
middle  of  the  night  or  in  the  early  morning.  Indigestible  foods  are  often 
well  borne,  while  at  other  times  small  meals  consisting  of  light  food  cause 
severe  symptoms.  Gastric  neurasthenia  is  sometimes  associated.  This 
condition  is  found  among  the  hysteric  and  neurasthenic. 

Diagnosis. — Anatomic  lesions  causing  these  symptoms,  intestinal 
dyspepsia,  and  enteroptosis  must  be  excluded. 

Treatment. — The  general  nervous  condition  must  be  toned  up;  iron, 
arsenic,  strychnin,  and  the  bromids  are  indicated,  and  ample  feeding  is 
required.  Indigestible  substances  should  be  avoided,  also  red  meats, 
to  lessen  the  nervous  irritability.  The  sour  milks,  such  as  bacillac, 
matzoon,  kefir,  etc.,  are  of  value. 

MUCOUS  COLIC  (MEMBRANOUS   ENTERITIS) 

Among  the  best-known  synonyms  for  mucous  coUc  are  mucous 
colitis,  membranous  coHtis,  membranous  or  pseudomembranous  enteritis, 
and  tubular  diarrhea.  In  all,  there  are  about  twenty-five  names  for  this 
condition. 

History.— Although  no  distinct  accounts  of  this  disease  occur  in  the 
writings  of  the  ancients,  yet  there  may  be  detected  some  of  its  peculiar 


go6  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

features  in  the  description  of  certain  pathologic  conditions  grouped  under 
diarrhea,  dysentery,  etc.  J.  Mason  Good,  in  1825,  was  the  first  to 
classify  the  disease,  calling  it  tubular  diarrhea.  Woodward  described  it 
in  the  "Medical  and  Surgical  History  of  the  War  of  the  Rebellion." 
Siredy  contributed  a  valuable  paper  in  1869.  DaCosta,  in  1871,  described 
the  nervous  elements  of  the  disease,  stating  that  the  condition  is  not  a  true 
inflammation.  Leyden's  work,  in  1882,  gave  further  stimulus  to  investiga- 
tion, especially  regarding  the  character  of  the  dejecta.  Nothnagel  sug- 
gested the  name  "mucous  colic,"  in  order  to  show  that  a  true  enteritis 
need  not  exist.  Mucous  colic  is,  therefore,  an  entity,  and  may  be  defined 
as  a  "condition  characterized  by  the  excessive  production  of  mucus  in 
the  colon,  by  attacks  of  painful  spasms  of  varying  degrees  of  severity  and 
frequency,  accompanied  or  followed  by  the  expulsion  of  mucus  in  gelatinous 
masses,  or  in  the  form  of  tubular  casts,  or  in  tape-like  pieces  or  strings,  and, 
furthermore,  characterized  by  anomalies  of  the  gastro-intestinal  functions 
and  by  various  nervous  symptoms." 

Age  and  Sex. — It  is  a  comparatively  rare  affection,  occurring  most 
frequently  in  women  from  twenty  to  forty,  frequently  in  middle  life. 
A  few  cases  occur  late  in  life  and  rarely  in  children.  Boas  reports  one 
in  early  infancy.     About  75  to  85  per  cent,  occur  in  women. 

Etiology. — Space  will  allow  me  to  mention  only  a  few  of  the  chief 
investigators.  Among  the  various  theories  regarding  the  etiology,  we 
may  mention  the  following: 

1.  Neurasthenia  is  the  prime  factor — mucous  colic  is  a  secretory 
neurosis.  Among  the  advocates  of  this  view  are  notably  DaCosta, 
Siredy,  and  W.  Mendelson,  of  New  York  City. 

Eppinger  and  Hess  hold  it  as  a  neurosis,  particularly  since  with  spastic 
constipation,  they  find  in  many  cases  the  masses  of  stool  covered  with 
mucus,  suggesting  increased  secretory  activity.  They  impute  these 
conditions  to  vagotonia. 

2.  The  anatomic  origin.  Ewald  lays  stress  on  ptosis  of  the  colon; 
Boas,  on  atony;  Glenard,  on  splanchnoptosis. 

3.  Partly  nervous  and  partly  anatomic  origin.  Mathieu  considers 
it  a  hypersecretion  of  mucus  in  patients  of  a  neuro-arthritic  type,  who 
suffer  from  enteroptosis,  intestinal  sand  being  present.  Hemmeter 
believes  that  often  there  is  some  connection  with  arthritis.  Von  Noorden 
lays  stress  on  long-continued  constipation  in  nervous  subjects.  Einhorn 
places  it  among  the  neuroses,  but  finds  that  it  is  associated  in  many  cases 
with  Glenard's  disease  (with  gastroptosis  and  enteroptosis),  and  that 
achylia  gastrica  is  present  in  many  patients. 

4.  Tumors,  adhesions,  enlarged  prostate,  and  various  other  factors 
are  given.  The  late  J.  P.  Tuttle  believes  mucous  colic  due  to  organic 
causes.  Roger  traces  the  cause  to  the  liver,  believing  there  is  an  anti- 
coagulant in  healthy  bile,  and  when  its  production  is  interfered  with  by 
visceral  ptosis,  abnormal  accumulation  of  mucus  begins. 

Nepper^  also  imputes  the  condition  to  disturbance  of  the  biliary 
functions. 

^  Mucomembranous  Colitis,  its  Causes  and  Mechanism,  New  York  Med.  Jour., 
May  23,  igo8. 


NERVOUS    DISEASES    OF    THE    INTESTINES  907 

Pathology. — Necropsies  are  rare  unless  death  results  from  some 
intercurrent  disease.  Autopsies  in  the  cases  of  O.  Rothmann,  Osier 
(Edwards),  and  Weigert  demonstrate  that  no  inflammatory  condition 
existed  in  the  colon.  There  was  simply  hypersecretion  of  mucus.  The 
consensus  of  opinion  is  that  no  inflammation  exists.  On  the  other  hand, 
M.  Rothmann  reports  one  case  and  Hemmeter  two  cases  in  which,  in  ad- 
dition, some  catarrhal  inflammation  was  present.  Nothnagel  explains 
this  unquestionably  by  the  fact  that  there  are  two  classes  of  cases,  one 
in  which  there  is  the  pure  "mucous  colic,"  with  hypersecretion  of 
mucus;  and  the  second  class,  in  which  the  mucous  colic  is  engrafted  on  a 
catarrhal  colitis.  I  have  noted,  in  my  own  experience,  that  the  catar- 
rhal colitis  may  be  of  such  a  mild  type  that  attention  may  readily  be  di- 
verted from  it  on  account  of  the  predominance  of  the  symptoms  of  the 
mucous  coUc. 

The  mucus  may  be  passed  in  the  form  of  long,  thin  bands,  ribbon- 
like or  in  the  shape  of  a  tapeworm;  they  may  be  tubular  or  form  a  cast  of 
the  intestines;  in  some  cases  these  are  of  considerable  length,  several  feet; 
the  mucus  may  be  in  jelly-like  masses  or  even  in  shreds,  occasionally 
streaked  with  blood.  This  discharge  should  be  carefully  differentiated 
from  fascia,  tendons,  the  membranes  of  oranges,  etc.  After  first  treating 
with  sublimated  alcohol  and  then  staining  with  Ehrlich's  triacid  solution, 
a  green  color  occurs  with  mucus,  of  which  this  discharge  consists;  with 
fibrin  it  turns  red.  The  color  of  the  membranes  in  mucous  coUc  is  or- 
dinarily grayish,  though  they  may  be  translucent  or  even  transparent. 
Microscopically,  the  membrane  consists  of  a  structureless  matrix,  with 
columnar  epitheUum  scattered  therein;  its  chief  constituent  is  mucus- 
Symptoms. — These  patients  are  markedly  neurasthenic  and  morbidly 
self-conscious;  in  appearance  they  are  usually  emaciated,  with  a  history 
generally  of  considerable  loss  of  weight.  There  has  been  obstinate 
constipation  of  long  duration,  with  an  occasional  intermittent  diarrhea. 
Palpitation,  dizziness,  disturbances  of  the  genito-urinary  system, hysteric 
symptoms,  anemia,  headache,  and  gastric  disturbances  of  various  types 
are  present. 

On  palpation  of  the  abdomen  sensitive  points  will  often  be  detected. 
Patients  give  a  history  of  a  sudden  attack  of  acute  abdominal  pain  like 
severe  colic,  and  the  abdomen  may  become  swollen  and  tense.  At  this 
time  the  nervous  symptoms  become  extremely  aggravated.  Finally, 
the  passage  of  the  mucous  masses  described  occurs  spontaneously,  with 
great  staining  or  with  artificial  aid.  These  attacks  occur  with  varying 
frequency  and  severity.  Between  the  attacks  the  nervous  condition  of 
the  patient  may  be  slightly  improved.  This  is  the  type  of  uncompHcated 
(pure)  mucous  colic. 

Nothnagel  describes  a  second  type  of  enteritis  membranacea  which  is 
engrafted  on  a  colitis.     He  notes  two  classes  of  cases: 

.  (a)  That  in  which  the  severe  cramp-like  attacks  are  absent;  the  patient 
passes  mucus  continuously,  with  occasional  tube-casts — a  cystic  colitis 
(Abercrombie's  case),  as  shown  at  autopsy.  This  is  not  a  true  mucous 
colic. 

(6)  A  class  in  which  mucous  colic  is  engrafted  on  a  chronic  catarrhal 


9o8 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


colitis — the  latter  due  in  this  case  to  adhesions  from  recurrent  appendicitis. 
There  were  small  amounts  of  mucus  passed  at  frequent  intervals  with 
occasional  attacks  of  mucous  colic.  Operation  relieved  both  conditions 
at  first,  but  the  mucous  colic  later  returned. 

I  have  had  such  a  patient  under  treatment;  the  appendix  had  been 
removed  and  adhesions  broken  up.  The  patient  improved  for  a  time,  but 
later  relapsed.  I  found  enteroptosis  associated  with  gastroptosis.  I 
applied  Rose's  belt  and  instituted  treatment.  Improvement  imme- 
diately followed,  with  ultimate  cure. 

Researches. — For  some  years  the  author  has  carried  on  investigations 
in  gastroptosis  and  enteroptosis  at  the  Manhattan  State  Hospital,  as 

well  as  other  institutions,  and  also  into  the 
etiology  of  mucous  colic,  ^  and  he  is  thoroughly 
convinced  that  enteroptosis  is  a  factor  in 
mucous  colic. 

In  Fig.  364  is  illustrated  ptosis  of  the  colon, 
narrowed  at  one  point  and  sacculated  above 
this.  Gastroptosis  is  associated  with  it.  This 
misplacement  of  the  colon  undoubtedly  favors 
circulatory  and,  hence,  secretory  changes  in 
the  sacculated  portion  of  the  colon.  Fecal 
accumulation  is  also  favored,  a  further  cause 
of  irritation.  Absorption,  with  resulting  auto- 
intoxication and  nervous  disturbances  following 
the  same,  can  thus  readily  result.  Naturally, 
a  patient  of  nervous  temperament,  and  there 
are  undoubtedly  many  such,  may  be  more 
Fig.  364.— Mucous  colic:  markedly  afifected,  but  I  do  not  believe  that 
Presence  of  gastroptosis   (G)  ^i       •       ,.  -n  ^i.    i.  t 

even  of   a  mUd  degree,  as   neurasthenia  per  se  will  cause  that  pecuhar 

demonstrable  by  gastrodi-  entity  known  as  mucous  colic  any  more  than 
aphany  shows  enteroptosis  jj-  ^jj  ^ause  gonorrhea.  There  must  be  other 
(E)    IS   present    also,    enter-     .  ° 

optosis   with   sacculation  and    factors. 

narrowing    at    ST;    passive  We   know    that   mucous    colic    occurs   in 

mr.lorc?ui  toTnlaTi  ^lenard's  disease,  that  Ewald  believes  tl,at 
(sacculated)  portion  of  colon;  ptosis,  and  Boas  that  atony,  of  the  colon  are 
mucous  colic  attacks  occur  as    important  factors,  and  Einhorn  finds  a  large 

percentage  of  patients  with  mucous  colic  that 
have   enteroptosis  associated    with    gastroptosis    and    achylia    gastrica. 

I  believe  that  mucous  colic  has  as  its  chief  etiologic  factor  ptosis  of 
the  colon  with  associated  gastroptosis. 

I  have  had  under  observation  a  patient  with  typic  attacks  of  mucous 
colic  which  began  one  month  after  confinement.  She  had  enteroptosis 
and  gastroptosis  (Landau's  disease)  due  to  insufficient  support  of  the 
abdomen  after  the  birth  of  her  child.  She  was  not  neurasthenic,  and 
was  only  nervous  at  the  time  of  her  attack. 

A  specimen  of  the  mucus  passed  by  this  patient  was  about  12  inches 
long,  flat,  and  tape-like,  and  gave  the  typic  reaction  to  the  mucin  test;  no 
fibrin  was  present.     To  my  knowledge,  this  is  the  first  case  of  mucous 
'  Amer.  Med.,  vol.  ix,  No.  9,  pp.  349-354,  March  4,  905. 


NERVOUS    DISEASES   OF    THE   INTESTINES  909 

colic  that  has  been  reported  without  the  usual  accompatiiment  of  neurasthenia, 
and  it  substantiates  my  views.  In  addition,  in  nine  cases  of  mucous  coUc 
which  I  have  carefully  examined  since  I  began  these  special  investigations, 
I  have  found  in  every  case  varying  degrees  of  gastroptosis  with  its  asso- 
ciated enteroptosis. 

In  four  cases  there  was  hyperacidity;  two  cases,  anacidity;  three  cases, 
achylia  gastrica.  Since  the  publication  of  the  above  article  the  author 
has  investigated  many  more  cases,  all  of  which  substantiated  this  view. 

In  the  newborn  and  in  young  children,  in  whom  several  cases  of 
mucous  colic  have  been  reported,  neurasthenia  surely  cannot  be  claimed 
as  a  cause  of  the  condition.  As  before  stated,  visceral  ptosis  may  be 
present  and  the  patient  be  in  perfect  health;  but  some  contributory 
factor,  local  irritation,  anemia,  or  intercurrent  disease  may  destroy  the 
equilibrium,  and  gastro-intestinal  disturbances,  constipation,  etc.,  may 
result,  and  finally,  mucous  colic.  On  the  other  hand,  gastro-intestinal 
ptosis  may  be  brought  about  by  loss  of  weight  or  other  factors  mentioned 
under  Etiology  of  Gastroptosis,  and  mucous  colic  finally  result.  Enterop- 
tosis is  not  invariably  productive  of  mucous  colic,  any  more  than  is  typhoid 
always  complicated  by  hemorrhage  or  perforation. 

Enteroptosis  with  associated  gastroptosis  with  gastro-intestinal  dis- 
turbances I  consider  factors  in  the  production  of  mucous  colic,  and  the 
neurasthenia  the  result  of  auto-intoxication.  In  effect,  it  may  be  con- 
sidered as  one  of  the  manifestations  of  Glenard's  disease.  Other  con- 
tributory factors,  such  as  rectal  irritation,  associated  colitis,  etc.,  will 
be  referred  to  under  Treatment.  In  a  paper  entitled  "A  Consideration 
of  the  Etiology  of  Mucous  Colitis,"  by  John  A.  Lichty,^  there  are  reported 
21  cases  of  mucous  colitis;  ptosis  of  the  viscera  was  demonstrated  in 
16  cases;  the  other  patients  were  seen  before  the  author's  attention  had 
been  directed  to  splanchnoptosis.  He  states  that  it  is  a  well-known  fact 
that  not  infrequently  during  the  examination  of  a  patient  a  condition  of 
ptosis  is  found  without  any  symptoms  referring  to  it.  In  such  cases  there 
has  been  established  what  may  be  called  a  condition  of  perfect  com- 
pensation, and  physiologic  function  has  not  been  disturbed.  When, 
however,  this  compensation  is  lost  or  disturbed,  the  symptom-complex 
of  mucous  colitis  appears.  He  notes  a  Uthemic  condition  in  several 
patients — notably  one  having  had  several  attacks  of  acute  articular  rheu- 
matism. The  gastric  secretion  was  studied  in  eight  patients— in  four  it 
was  hyperacid;  in  two,  normal;  in  one,  hypo-acid,  and  in  one,  achylic. 
G.  H.  Koehler'  reports  a  case  of  mucous  colic  clearly  dependent  on 
gastroptosis. 

Prognosis. — These  cases  require  tact  and  patience  and  most  of  them 
are  of  long  duration.     With  perseverance,  I  believe  them  to  be  curable 

Treatment. — This  may  be  summarized  as  follows:  During  the  attack, 
rest  in  bed;  the  application  of  heat  to  the  abdomen  by  flax-seed  poultices, 
turpentine  stupes,  or  hot  pepper  poultices — i  dram  (4.0)  red  pepper  to 
I  pint  (500  c.c.)  of  boiUng  water — a  flannel  being  wrung  out  therein, 

^  Med.  News,  Aug.  6,  1904;  Amer.  Med.,  March  4,  1905. 

*  Amer.  Med.,  Aug.  6,    1902. 

'  Med.  Sent.,  June,  1909,  Portland,  Oregon. 


9IO  DISEASES   OF   THE   STOMACH   AND    INTESTINES 

covered  with  oiled  silk,  and  applied  to  the  abdomen.  Dry  heat,  by  means 
of  a  hot- water  bag,  salt-bag,  or  light  tinplate  (pie  plate),  heated  in  the 
oven  and  covered  with  flannel,  may  be  employed.  Spice  poultices  are 
of  service.     Moist  heat,  however,  seems  best. 

The  greatest  relief  to  the  cramps  and  bearing-down  pains  is  afforded 
by  enteroclysis  by  recurrent  irrigation  with  normal  saline  solution  at 
iio°  to  i20°F.,  oil  of  peppermint,  5  to  15  minims  (0.296-0.888)  to  the  quart 
(liter),  may  be  added.  Several  gallons  should  be  employed  once  or  twice 
in  twenty-four  hours,  and  no  fluid  should  be  left  in  the  bowel  after  irriga- 
tion, lest  further  cramps  ensue.  High  enemata  of  warm  olive  oil — -i  pint 
to  I  quart  (500  c.c.  to  i  liter) —  are  also  of  service,  as  they  aid  in  relieving 
spasm  just  as  does  the  internal  administration  of  olive  oil  in  spasm  or 
stenosis  of  the  pylorus.  Hot  saline  rectal  injections  containing  2  to  4 
ounces  (60.0-125.0)  of  milk  of  asafetida  may  be  employed. 

Diet. — Fluid  diet,  milk,  sour  milk,  broths,  soups,  etc.,  should  be  enjoined 
during  an  acute  attack. 

Medication. — Tincture  of  belladonna  in  doses  of  10  gtts  every  three 
or  four  hours,  and  pushing  even  to  physiologic  symptoms,  has  given  me 
the  best  results  in  the  treatment  of  spasm,  and  increased  secretion  of 
mucus.  Atropin  gr.  >f  00  to  y^Q,  three  to  four  times  daily  may  give  better 
results.  Occasionally  it  may  be  necessary  to  employ  codein  in  0.016  to 
0.03  gram  {}i-H  gr.)  doses,  or  even  morphin,  0.008  to  0.016  gram 
i/4-H  gr.)>  in  conditions  of  extreme  pain.  If  the  acute  attack  is  rather 
prolonged,  the  internal  administration  of  valerianates  or  of  asafetida,  and 
the  addition  of  milk  of  asafetida  to  the  enema  may  prove  to  be  of  value. 

Between  attacks  I  apply  proper  abdominal  support.  For  this  purpose 
a  silk  elastic  abdominal  supporter,  the  Van  Valzah-Hayes  support, 
Gallant's  or  La  Grecque  corset,  or  Rose's  adhesive  plaster  belt  can  be 
used.  Rose's  belt  has  the  advantage  of  simplicity  and  it  cannot  slip  or 
become  displaced. 

My  great  object  is  to  "put  on  fat"  in  all  cases,  and  as  ptosis  of  the 
colon  of  the  stomach  are  great  factors  in  the  disease,  the  increase  of 
intra-abdominal  tension  should  be  secured  by  this  means.  The  belt  is 
an  aid  in  the  relief  of  the  functional  disorders  of  the  stomach  incident  to 
the  gastroptosis.  If  the  patient  objects  to  the  plaster,  then  the  silk 
abdominal  supporter  may  be  employed,  or  Lane's  spring  pad  in  the  male. 
In  exceptional  cases  it  may  be  necessary  to  resort  to  the  rest  cure,  asso- 
ciated with  hydrotherapy  and  electrotherapeutics.  Under  such  condi- 
tions we  may  increase  the  weight  by  following  out  Russell's  method,  such 
as  he  first  instituted  at  the  Post-Graduate  Hospital  in  the  treatment  of 
tuberculosis.  It  was  advocated  by  me  in  cases  of  gastroptosis.  Regard- 
ing the  constipation,  the  Kiissmaul-Fleiner  method  of  injecting  into  the 
rectum  nightly  or  every  other  night  warm  olive  oil,  to  be  retained  all 
night,  is  of  great  value.  At  the  beginning  one  may  employ  a  few  ounces, 
increasing  it  to  i  pint  (500  c.c.)  or  even  i  quart  (liter).  The  patient  should 
be  taught  regular  habits  in  attempting  bowel  movement.  A  glass  of  hot 
or  cold  water  administered  an  hour  before  breakfast  is  valuable  as  an 
adjunct.  Fluidextract  of  cascara  sagrada  or  the  compound  cascara 
tablets  have  been  found  serviceable,  and  in  some  cases  sodium  phosphate 


NERVOUS   DISEASES    OF   THE   INTESTINES 


911 


administered  in  the  morning  is  of  value,  or  regulin,  or  the  mineral  oils  or 
olive  oil.  Other  remedies,  as  suggested  under  Chronic  Constipation, 
can  be  employed.  A  thorough  bowel  action  should  be  secured  daily. 
Massage  of  the  bowel  may  be  employed,  massage  with  a  cannon-ball, 
or  vibratory  massage.  Sensitive  areas  must  be  avoided.  These  methods 
can  be  used  while  Rose's  belt  is  in  situ. 

Enteroclysis  several  times  a  week  with  normal  saline  solution  is  useful, 
since  it  promotes  intestinal  peristalsis,  prevents  the  accumulation  of 
mucus,  and  lessens  the  chances  of  spasmodic  attacks.  With  obstinate 
constipation  electric  saline  enteroclysis  is  of  value.  In  addition  I  some- 
times employ  baths,  abdominal  compresses,  and  electricity. 


Fig.  365. — Rose's  dry  carbonic  acid  gas  bath. 

The  carbonic  acid  bath  (Nauheim)  is  of  value  in  improving  the  circu- 
lation. For  the  nervous  conditions  the  same  bath  (Triton  salts)  has 
proved  of  service.  The  late  Achilles  Rose  has  devised  a  simple  method  for 
administering  the  dry  gas  bath  without  the  patient  being  obliged  to 
disrobe  (Fig.  365).  Rose  has  recently  improved  on  the  dry  bath  apparatus, 
so  it  is  possible  to  enter  it  on  the  floor  level  without  climbing  up  steps. 

The  tank  is  filled  with  gas  and  the  patient  sits  therein.  The  height 
to  which  the  gas  rises  is  estimated  by  means  of  a  burning  candle,  which 
goes  out  when  the  gas  reaches  that  point. 

I  have  secured  at  least  one  brilliant  result  in  the  treatment  of  mucous 
colic  by  inflation  of  the  colon  with  CO2  gas,  as  advocated  by  Dr.  Rose. 
The  method  seems  in  some  cases  to  improve  the  local  circulatory  condi- 


912  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

tions  in  the  colon,  just  as  it  affects  the  peripheral  circulation  when  the 
bath  is  given.  I  believe  it  worthy  of  trial  as  an  adjunct  to  the  other 
treatment. 

It  merely  requires  a  bottle  with  a  large  mouth.  A  glass  tube  passes 
through  the  cork.  To  this  tube  is  attached  a  piece  of  rubber  tubing  with 
a  rectal  tip.  From  \i  to  i  dram  (2.0-4.0)  each  of  bicarbonate  of  soda  and 
tartaric  acid  are  placed  in  the  bottle,  which  is  then  filled  two-thirds  with 
water.  The  CO2  gas  is  thus  generated,  and  the  bottle  being  elevated 
slightly  above  the  rectum,  the  gas  is  allowed  to  flow  in  until  slight  dis- 
tention is  observed.  This  procedure  can  be  carried  out  every  other  day. 
Rose's  CO2  bottle  is  illustrated  in  this  volume. 

I  have  referred  to  certain  mixed  cases  in  which  there  was  a  catarrhal 
colitis  with  a  mucous  colic  later  engrafted  upon  it.  Among  such  we  can 
classify  those  that  may  apparently  be  caused  by  excessive  bicycling  or 
horseback  .riding,  enlarged  prostate,  uterine  fibroids,  adhesions  from 
appendicitis,  etc.  In  some  of  these  conditions  a  local  congestion  of  the 
rectum  or  sigmoid  can  be  detected,  and  careful  investigation  will  demon- 
strate that  the  attack  first  starts  as  a  simple  proctitis  or  colitis.  Consti- 
pation has  been  previously  present.  Subsequent  auto-intoxication, 
nervous  symptoms,  and  mucous  colic  result.  I  believe  that  careful  exami- 
nation will  reveal  that  these  patients  have  had  an  existing  ptosis  of 
stomach  and  colon,  quiescent,  with  no  resulting  symptoms,  but  as  a  result 
of  irritation  causing  favorable  conditions,  mucous  colic  develops.  The 
correction  of  such  sources  of  irritation  is  undoubtedly  rational,  and 
wiU  thus  readily  explain  the  improvement  which  at  all  times  occurs 
after  operative  procedure,  as  in  the  chronic  appendicitis  case  with 
colitis  and  mucous  colic  previously  described.  The  existence  of  the 
*' mixed  cases"  will  undoubtedly  "clear  up  "the  hitherto  apparently 
diverse  opinions  as  regards  the  etiology  of  this  disease. 

In  such  cases,  with  a  coexisting  catarrhal  colitis,  irrigation  with  nitrate 
of  silver,  i  .3  to  2  grams  (20-30  grains)  to  2  quarts  of  water,  and  followed 
by  saline  solution,  or  argyrol  or  protargol  1-2,000,  or  with  resorcin,  0.65 
to  1.3  gram  (10-20  grains)  in  2  quarts,  or  with  listerin,  borolyptol,  gly- 
cothymolin,  4  to  8  grams  (1-2  drams)  to  2  quarts,  or  with  gomenol, 
4  grams  (i  dram)  in  the  same  quantity  of  water,  may  prove  to  be  of  ser- 
vice. I  have  often  found  enteroclysis  with  demulcents,  such  as  weak 
flaxseed  tea,  or  6  to  8  ounces  (185-250  c.c.)  of  a  saturated  solution  of  gum 
arable  added  to  2  quarts  (liters)  of  warm  water,  of  value. 

In  pure  mucous  colic  I  employ  only  normal  saline  solution  or  the 
demulcents  for  removal  of  the  mucus,  since  the  conditions  is  due  to 
hypersecretion  and  not  to  inflammation.  I  should  avoid  silver  irriga- 
tions in  such  cases,  since  I  have  already  referred  to  the  fact  that  irriga- 
tions of  silver,  tannin,  alum,  etc.,  can  produce  an  artificial  hypersecretion. 
Small  doses  of  olive  oil  or  of  castor  oil,  in  capsules,  seem  of  value  for  con- 
stipation, and  improve  the  tone  of  the  mucous  membrane  of  the  intestines, 
providing  they  do  not  increase  the  patient's  dyspeptic  symptoms. 

Extract  of  nux  vomica,  K  grain  (0.016),  or  strychnin,  J^o  grain 
(0.00108)  t.i.d.,  is  of  service  in  increasing  the  tone  of  the  gastro-intestinal 


NERVOUS    DISEASES    OF   THE   INTESTINES  913 

tract  and  the  general  muscular  system.  Resorcin,  5  grains  (0.3),  or  sodium 
benzoate,  5  to  10  grains  f 0.3-0,6),  or  bismuth  salicylate,  5  to  10  grains 
(0.3-0.6),  should  be  given  if  there  is  much  gastro-intestinal  fermentation. 
The  use  of  the  following,  suggested  by  W.  H,  Thomson  in  the  mixed  cases 
for  the  treatment  of  catarrh,  gives  good  results: 

I^.  Silver  nitrate 0.32  gm.  (gr.  v); 

Resin  of  turpentine 8.0    gm.  (3ij); 

Potash  solution 4.0    gm.  (3j)- 

Pulverized  licorice,  q.  s.  to  make  pills  soft. — M. 
Divide  into  60  pills. 
Sig. — Three  pills  t.i.d. 

Copper  sulphate,  ]4  grain  (0.016)  t.i.d.,  may  be  substituted  later; 
Fowler's  solution  of  arsenic  in  i -minim  (0.06  c.c.)  doses  t.i.d.  has  also 
been  found  useful  in  these  mixed  cases. 

General  Treatment. — Exercise^  and  outdoor  life,  as  golf,  etc.,  to 
strengthen  the  abdominal  muscles,  are  important.  During  winter  weather 
fencing  is  useful.  The  general  nervous  system  must  be  toned  up  and 
anemia  should  be  corrected.  Iron  tropon  is  easy  to  assimilate.  An 
excellent  combination  is  a  fresh  Blaud's  pill  (iron),  5  grains  (0.32  grams), 
made  soft  with  honey;  in  each  pill  is  incorporated  2  minims  (0.118) 
Fowler's  solution  of  arsenic,  and  extract  of  nux  vomica  %  grain  (0.008 
gram),  or  sod.  arsen.,  J^o  grain  (0.00108),  with  %o  grain  (0.00108  gram) 
of  strychnin.  The  glycerophosphates  or  phosphorus  compounds  are  of 
value  for  the  nervous  conditions.  Hydrotherapy,  massage,  and  electro- 
therapy may  be  used. 

Diet. — As  before  noted,  fluid  diet,  milk,  koumiss,  bacillac,  fermillac, 
lactone-buttermilk,  broths,  gruels,  etc.,  with  the  addition  of  somatose  or 
liquid  peptonoids,  should  be  used  during  the  attacks.  Between  attacks, 
Von  Noorden  advocates  a  very  coarse  diet  (bread  containing  plenty  of 
chaff,  vegetables  rich  in  cellulose,  fruits  with  skins,  etc.),  to  form  ballast 
for  the  bowel.  He  claims  excellent  results.  It  is  my  custom  to  determine 
the  condition  of  the  stomach.  Like  Einhorn,  I  have  found  cases  of  achylia 
gastrica  in  mucous  colic,  but  more  cases  of  hyperchlorhydria  and  a  few 
of  hypochlorhydria.  These  special  conditions  should  be  treated  in  each 
individual  case  and  appropriate  diet  instituted.  Stomachics  and  dilute 
hydrochloric  acid  should  be  given  when  there  is  deficiency  of  HCl,  and 
alkalis  if  there  is  hyperacidity  (see  Hyperchlorhydria,  Achylia  Gastrica, 
etc.).  We  should,  however,  give  our  patient  abundant  nutrition.  Cod- 
liver  oil  and  fats,  such  as  Russell's  emulsion,  cream, ^  etc.,  are  of  value 
when  they  can  be  assimilated.  The  addition  of  healthy  fat,  with  increase 
in  weight,  means  the  cure  of  our  patient. 

Surgery. — Some  writers,  notably  Hale  White,  have  recommended  a  right 
inguinal  colotomy  to  give  rest  to  the  colon  in  certain  intractable  cases. 
This  would  not  relieve  the  ptosis,  however.  In  severe  cases  one  might 
resort  to  shortening  the  suspensory  ligaments  of  the  stomach  and  colon. 
Gastropexy  and  colopexy  might  be  performed,  but  to  my  mind  it  is 

^  Exercise  should  not  be  sufficiently  active  to  cause  loss  of  weight,  as  the  object  is 
to  increase  the  latter. 

^  Butter  is  indicated  in  considerable  quantity. 
S8 


914  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

always  objectionable  to  suture  a  viscus  to  the  abdominal  wall.  If  there  is 
hepatoptosis,  Elliot's  operation  for  support  of  the  liver  might  be  insti- 
tuted at  the  same  time.  These  procedures  will  aid  in  the  support  of  the 
floating  kidney  if  such  be  present.  Nephropexy,  I  believe,  is  rarely  indi- 
cated when  it  is  a  part  of  general  ptosis,  unless  there  be  some  evidence  of 
nephritis  or  interference  with  its  functions.  Some  recommend  a  "revi- 
sion" (tightening)  of  the  abdominal  muscles  (recti)  by  means  of  suturing, 
so  as  to  relieve  the  muscular  relaxation.  This  last  procedure,  as  advocated 
by  R.  T.  Moris,  I  consider  preferable.  I  believe  that  resort  to  surgery  is 
rarely  required  except  in  the  most  obstinate  cases,  and  only  after  at  least 
two  years'  continuous  medical  treatment,  with  failure  to  secure  cure  or 
comparative  comfort  for  the  patient. 


CHAPTER  XXXVI 

OBESITY 

Obesity  may  be  defined  as  a  disorder  of  metabolism  characterized 
by  an  excessive  deposit  of  fat  in'  the  tissues  of  the  body. 

Etiology. — It  results  from  inadequate  oxidation  of  the  food,  in  associa- 
tion with  incomplete  combustion,  or  with  excessive  absorption  of  the  fat- 
producing  materials.  Both  factors  may  be  concerned  in  the  process. 
Excessive  intake  of  food  is  not  always  a  cause,  as  frequently  stout  persons 
are  light  eaters,  while  in  others  excessive  eating  may  produce  increase  in 
weight.  There  is  evidently  an  hereditary  tendency  and  some  races  are 
prone  to  it  and  it  is  more  likely  to  affect  women,  and  to  appear  after  middle 
life.  It  occurs  in  children  from  improper  feeding  and  in  such  is  at  times 
associated  with  rickets.  Sedentary  life  tends  to  produce  it,  as  does  also 
the  excessive  use  of  alcohol,  particularly  malt  beverages  such  as  beer. 
Gout  has  been  considered  a  factor.  Fat  metabolism  is  under  the  control 
of  the  internal  secretions.  It  is  interesting  to  observe  the  deposition  of 
fat  in  connection  with  processes  with  which  the  internal  secretions  are 
concerned;  thus  fat  deposits  at  puberty,  during  pregnancy,  lactation  and 
at  the  menopause.     Obesity  frequently  follows  castration. 

It  is  believed  that  some  cases  of  extreme  obesity  in  young  persons  result 
from  hypopituitarism,  as  there  is  an  increased  tolerance  for  carbohydrates 
with  the  adipose  condition.  Sudden  access  of  extreme  adipose  is  probably 
dependent  in  part  at  least  upon  perversion  of  some  of  the  internal 
secretions.     Fat  may  be  derived  from  any  of  the  three  classes  of  food. 

Symptoms. — Women  usually  consult  the  physician  for  this  condition, 
chiefly  on  account  of  loss  of  good  looks,  or  inconvenience  produced  by 
their  bulk,  in  walking  for  example.  The  round  face,  double  chin  and 
great  girth  are  familiar  objects.  Some  obese  individuals  may  be  quite 
vigorous  and  active.  Many,  however,  suffer  from  shortness  of  breath, 
particularly  on  exertion,  such  as  climbing  stairs;  heart  action  may  be 
disturbed  and  walking  is  difl&cult.  Digestive  disturbances  may  occur, 
and  the  bowels  may  be  constipated.  The  liver  may  become  enlarged. 
Sexual  disturbances  among  women  may  be  aggravated  and  intertrigo 
may  occur  where  two  skin  surfaces  ar^  in  apposition  such  as  in  the  groin 
and  about  the  breasts.  In  young  persons  there  may  be  an  uncontrollable 
desire  to  sleep  in  the  day  time. 

Prognosis. — This  is  usually  good  unless  fatty  degeneration  of  the  heart, 
liver,  etc.,  occur  with  their  associated  symptoms. 

Treatment. — Prevention. — Considerable  may  be  done  in  the  way  of 
prevention.  Thus  the  starches  and  fats  should  be  markedly  reduced, 
candy  and  soda  water  should  be  cut  off,  and  sugar  reduced  to  a  minimum, 
one  lump  of  sugar  to  a  cup  of  tea  for  example.  Pastry  and  sweet  desserts 
should  be  forbidden — fruit  is  preferable  as  a  dessert,  with  occasionally  a 
small  custard  sweetened  with  saccharin  or  a  small  quantity  of  "poor 
man's  rice  pudding." 

915 


91 6  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Regular  exercise  in  the  open  air  should  be  enjoined,  in  an  adult  begin- 
ning at  I  to  2  miles  and  increasing  to  3  to  5  miles  daily  in  fine  weather. 
In  bad  weather,  the  use  of  exercising  machines  or  walking  about  the  room 
with  windows  open  and  massage  are  all  of  value.  Cold  salt  baths  if  the 
reaction  is  good,  or  hot  alkaline  baths  every  other  day  may  be  of  service. 
If  at  any  time  the  patient  feel  a  little  weak  during  the  treatment,  the  diet 
is  increased. 

Diet  for  Reduction  of  Obesity  .^Various  systems  have  been  suggested. 
Banting's  is  probably  one  of  the  best  known.  He  eliminates  carbohy-* 
drates  and  fats  from  the  diet,  allows  a  considerable  amount  of  proteid  in 
the  form  of  lean  meat,  and  permits  green  vegetables.  Water  and  alcohoUc 
drinks  are  not  forbidden.     The  amount  of  food  is  greatly  reduced. 

Oertel  reduces  the  amount  of  ingested  fluids,  allowing  in  all  daily  about 
36  ounces  of  liquid  including  the  amount  taken  with  the  solid  food  only 
about  a  pint  of  pure  water  is  given  daily,  the  balance  of  liquid  as  tea, 
etc.  Free  perspiration  is  promoted  by  bathing  (by  Turkish  baths  in  some 
cases)  or  occasionally  by  the  use  of  pilocarpin.  The  bowels  are  kept 
open.     The  diet  consisting  largely  of  proteids  is  as  follows: 

Breakfast. — Cup  of  cofifee  or  tea  with  a  little  milk,  in  all  6  ounces,  bread,  3 
ounces. 

Lunch. — Three  to  4  ounces  of  soup,  7  to  8  ounces  roast  beef,  veal,  poultry  or 
game,  salad  or  light  vegetable,  a  little  fish,  i  ounce  of  bread  or  farina 
pudding;  3  to  6  ounces  of  fruit.  No  water  at  this  meal.  In  hot  weather 
6  ounces  of  light  wine  in  some  cases. 

Afternoon. — Six  ounces  of  tea  or  coffee  and  an  equal  amount  of  water.  Occa- 
sionally as  an  e.xtra  an  ounce  of  bread. 

Supper. — One  or  two  soft  boiled  eggs;  an  ounce  of  bread;  in  some  cases  a  small 
piece  of  cheese,  salad  and  fruit,  6  to  8  ounces  of  wine  with  4  to  5  ounces 
of  water.  Graduated  exercise  (walking)  should  be  taken,  not  on  the  level, 
but  up  hills  of  various  grades.    The  distance  should  be  gradually  increased. 

Ebstein  restricts  the  quantity  of  food  ingested,  but  allows  fats  and 
carbohydrates  in  considerable  amount  but  forbids  sweets  and  potatoes. 
Von  Noorden's  diet  is  as  follows: 

Breakfast,  8.00  a.  m. — 80  gm.  lean  cold  meat;  25  gm.  bread;  one  cup  tea  with 

spoonful  of  milk,  no  sugar. 
10.00  A.  M. — One  egg. 
12.00  noon. — Cup  of  strong  meat  broth. 
1.00  p.  M. — Small  plate  meat  soup  flavored  with  vegetables;  150  gm.  lean  meat 

(one  or  two  varieties)  partly  flesh,  partly  fish;  100  gm.  potatoes;  salad;  loo 

gm.  fresh  fruit  or  compote  without  sugar. 
4.00  p.  M. — 200  gm.  fresh  fruit. 

6.00  P.M. — Quarter  of  a  liter  of  milk,  with  tea  if  desired. 
8.00  P.M. — 125  gm.  cold  meat  weighed  raw  and  grilled,  and  eaten  with  pickles  or 

radishes  and  salad;  30  gm.  graham  bread  and  2  to  3  spoonfuls  of  cooked 

fruit  without  sugar. 

Von  Noorden  believes  additional  small  feedings  should  be  given  to 
prevent  the  tendency  to  weakness. 

He  allows  twice  daily  a  glass  of  wine;  mineral  water,  weak  tea  or 
lemonade  is  not  limited  at  the  meal  time,  or  between  meals.  Occasionally 
a  "hunger  day"  is  given. 


OBESITY  917 

Dujardin-Beaumetz  recommends  as  follows: 

Breakfast  7.00  a.  m. — Bread  6]ri  drams;  cold  meat  without  fat,  12!-^^  drams;  6 
ounces  of  weak  tea. 

Luncheon  12.00  noon. — Bread  i2y>  drams  preferably  the  crust;  meat  3  ounces  or 
two  eggs;  green  vegetables  3  ounces;  salad;  3  drams  cheese;  cooked  fruit 
for  dessert. 

Dinner  7.00  A.M. — No  soup;  dry  bread  121,^ drams;  meat 3  ounces  including  vege- 
tables, salad,  cheese  and  fruit  as  at  luncheon.  The  fluids  are  reduced  and 
pastry  and  sweets  are  forbidden.  Starches  are  cut  down  to  a  minimum  and 
half  a  glass  of  light  white  wine  is  allowed  with  luncheon  and  dinner.  Alka- 
line waters  can  be  taken  as  may  also  a  small  cup  of  black  coffee  after  dinner. 
In  place  of  taking  fluid  at  meals,  he  holds  it  is  better  to  omit  them  and  two 
hours  after  eating  take  a  glass  of  white  wine  mixed  with  two  parts  of  water 
or  a  large  cup  of  weak  tea  without  sugar.  Occasionally  it  may  be  necessary 
to  give  small  quantities  of  suitable  food  between  meals  to  prevent  weakness. 

The  writer  believes  restriction  of  liquid  as  extensively  as  advocated  by 
Oertel  often  does  positive  harm.  In  his  own  experience  he  knows  of  a 
case  who  thus  first  produced  hyperacidity  and  gravel  and  later  nephritis 
resulted  with  a  fatal  issue.  Von  Noorden's  diet  seems  far  too  rich  in 
protein,  placing  too  much  work  on  the  excretory  organs. 

Precautions. — There  are  certain  definite  precautions  to  be  taken  in  the 
attempt  at  fat  reduction.  In  extremely  severe  cases,  it  is  better  for  the 
patient  for  a  time  at  least  should  be  in  a  hospital  under  the  care  of  a  com- 
petent nurse.  This  is  particularly  true  if  the  patient  be  very  short  of 
breath,  ot  have  fatty  accumulation  about  the  heart  or  fatty  degeneration 
and  suffer  from  cardiac  asthma,  dizziness,  bronchitis,  etc.  From  the 
diminution  of  the  diet,  some  patients  may  complain  of  weakness,  in  which 
event  more  calories  must  be  added  in  the  form  preferably  of  carbohydrates 
and  fats.  At  the  time  of  change  of  diet,  there  may  be  at  first  no  loss  of 
weight  but  even  a  slight  gain.  Too  rapid  loss  of  weight^  is  to  be  avoided. 
The  writer  is  perfectly  satisfied  if  he  can  reduce  the  patient  about  2  to  3 
pounds  a  week.  At  this  rate  of  reduction,  weakness  is  not  as  a  rule  com- 
plained of.  Rapid  reduction  will  also  often  produce  marked  facial 
wrinkles  and  seriously  damage  the  personal  appearance. 

Author's  Diet. — The  writer  cuts  down  markedly,  fats,  starches,  and 
sugars.  One  should  vary  the  diet  in  each  case  and  feed  rather  by  the 
"scales,"  causing  a  reduction  in  weight  of  about  2  to  3  pounds  weekly. 
Individual  cases  can  assimilate  more  carbohydrates  and  fats  than  others 
without  increasing  in  weight.  The  patient  should  be  weighed  at  least 
twice  to  three  times  weekly  when  an  ambulant  case,  and  always  in  the 
same  weight  clothes.  In  hospital  cases  I  weigh  them  daily.  Here  are 
two  sample  diets  for  individual  cases. 

Diet  I  Diet  2  (more  restricted) 

Breakfast. — One  to  two  soft  boiled  eggs.       8.00  a.m. — Zoolak  and  Vichy  (equal  parts) 
8.00  A.  M. — Cup  of  tea  with  a  little  milk  or         mixed,  one  to  two  glasses   (5vi  each 
cup  of  coffee  (weak)  sweetened  with  sac-        glass)  one  to  two  whole  wheat  crackers; 
charin.     Total,   6  ounces  tea  or  coffee.         one  apple,  or  fruit  only. 
One  to  two  whole  wheat  crackers  {Wheats- 
worth  for  example),     i  glass  water,  5vi 
^  Acidosis  the  writer  believes  may  result  from   too  rapid   fat  reduction  and  too 
marked  restriction  of  diet  in  some  patients.    The  urine  should  be  frequently  examined 
during  reduction  cure. 


9l8  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

drunk  slowly,  no  buUcr,  i  orange  or  apple, 

lo.oo  A.  M. — Water  8  to  1 2  ounces  or  Vichy  lo.oo  a.  m. — Water    38-i2    or    same 

one  day  and  Kissingen  the  next,  same  amount  Vichy  or  Kissingen. 

amount, 

i.oo  P.M. — No  soup,  no  butler.     Fish  (boil-  i.oo  p.  M. — Plate  of  broiled  rice  (loogm.). 

ed,  broiled  or  baked).    loogm.  (3  ounces).  Small    piece    of    fish     (75    gm.)     one 

Spinach    100    gm.    (small    dish).      One  whole  wheat  biscuit;  fresh  cooked  fruit 

to    two    whole    wheat    crackers.     One  (no  sugar).     Tea   5vi  (no  sugar)  but 

poached  egg  (no  toast)  fruit  cooked  with-  saccharin  and  a  little  milk. 

out  sugar.    Tea  5  vi  (no  sugar)  sweetened 

with  saccharin  with  a  little  milk. 

3.30  p.  M. — Water,    Vichy,    or    Kissingen,  3.30  p.  m. — Same  liquids  as  diet  i. 

8-12. 

6.30  p.  M. — Meat   (hot  or  cold  lean),  two  6.30  p.  M. — Chops,  small   chicken,  etc., 

chops  or  steak,  chicken,  turkey  or  duck  but  only  100  gm.     One  whole  wheat 

about  150  gm.;  one  to  two  whole  wheat  cracker;     spinach     100     gm.;  lettuce, 

crackers;  spinach  100   gm.;  no    butter,  pickles,     radishes;    cooked    fruit     (no 

lettuce,  pickles  or  radishes,  black  coffee,  sugar), 

small  cup,  water  5  iv,  compote  or  stewed 

fruits  (no  sugar). 

9-9.30  p.  M. — Water,  etc.,  57~i2  as  at  3.30  9-9-30  p.  m. — Same  liquids  as  diet  i. 

P.  M. 

No  wine  is  given.  It  is  possible  to  substitute  another  carbohydrate 
for  rice,  such  as  potato  or  some  cereal.  If  the  patient  feels  weak  or 
is  losing  too  rapidly,  more  carbohydrate  and  fat  (butter)  should  be  added 
to  the  diet.  It  can  be  used  between  meals.  If  indicanuria  is  present 
red  meat  should  be  cut  out  and  the  putrefactive  condition  receive 
appropriate  treatment. 

Baths. — The  hot  mineral  baths  (various  alkaline  salts)  advocated,  seem 
to  act  chiefly  in  the  production  of  sweating.  Some  cases  cannot  undergo 
depressing  treatment  by  the  hot  baths.  Ordinarily  duration  of  hot  baths 
should  be  eight  to  fifteen  minutes  depending  on  the  pulse  and  given  daily 
or  every  other  day.  Several  pounds  of  salt  (5  lb.),  or  3  pounds  washing 
soda  to  the  baths  may  be  used.  Some  cases  do  well  with  the  Turkish 
bath  but  with  circulatory  disturbances  present,  it  should  not  be  employed. 
The  artificial  Nauheim  baths  (Triton  salts)  are  of  value  for  the  latter  class. 

Exercise. — To  reduce  the  waist-line,  extension  of  the  arms  above  the 
head,  holding  the  arms  and  knees  stiff  and  flexing  the  hips,  bending  for- 
ward and  endeavoring  to  touch  the  toes  with  the  fingers,  15  to  25  move- 
ments A.  M.  and  p.  M.  are  of  service.  Dorsal  posture  with  thigh  flexion 
and  leg  extended  may  also  be  tried.  Graded  exercise  should  be  given 
commencing  at  i-mile  walk  per  day  and  gradually  increasing  to  2  to  3  to 
5  miles  daily.  Horseback,  bicycling,  and  gymnastics  may  be  required. 
Massage  and  vibratory  massage  are  of  service. 

The  bowels  should  be  kept  open  for  which  purpose  Carlsbad  salts, 
phosphate  of  soda,  and  magnesium  or  sodium  sulphate  are  useful. 

The  spa  treatment  at  Carlsbad  or  Marienbad  may  be  advisable  in 
some  cases  as  the  systematic  mode  of  life  enjoined  at  these  resorts  is  most 
valuable. 

The  daily  quantity  of  urine  should  be  watched  carefully  and  if  neces- 
sary additional  water  be  given  to  preserve  the  normal  secretion. 

Many  of  these  patients  are  anemic  and  require  iron. 


OBESITY  919 

An  excellent  pill  is 


I^  Blauds  iron  pill gr.  v.  1 

Sod.  arsen gr.  }4o  J 

Make  salt  with  honey;  silver  coat. 
Sig. — One  t.i.d.  after  meals. 


piU. 


If  the  circulation  is  poor,  gr,  }4o  strychnin  t.i.d.  can  be  added. 

Thyroid  extract  (dried)  gr.  3  to  5  t.i.d.  may  be  useful  if  cautiously 
employed,  in  some  cases.  The  detoxicated  thyroid  made  by  Burroughs 
and  Wellcome  or  thyroidin,  a  French  preparation  are  suggested. 

Pituitajy  gland  extracts  have  also  been  employed. 

Phytolacca  and  many  other  preparations  advocated,  only  act  through 
disturbing  the  appetite  and  producing  purgation. 

lodin  with  the  alkaUne  iodids  have  been  suggested. 


CHAPTER  XXXVII 
INTESTINAL  PARASITES 

Most  of  the  animal  parasites  that  occur  in  mankind  inhabit  the  intes- 
tinal canal.  There  are  about  fifty  varieties,  but  all  do  not  produce 
morbid  conditions.  Some  cause  a  pathologic  state  locally  in  the  intestines 
or  by  their  toxins  in  the  blood.  There  are  no  absolutely  characteristic 
symptoms  produced  by  these  parasites,  but  they  are  detected  by  dis- 
covering either  them  or,  in  the  case  of  worms,  their  ova  in  the  stools. 

Gastro-intestinal  disturbances,  with  or  without  anemia  and  with 
nervous  symptoms,  may  result  from  their  presence.  There  are  two 
chief  groups — the  protozoa  and  the  vermes.  In  passing,  it  is  interesting 
to  note  that  certain  fungi  have  spread  from  the  mouth  to  the  lungs,  in 
some  cases  causing  symptoms  resembling  tuberculosis.  Thus,  Castellani^ 
has  reported  tropical  bronchomycosis  with  the  oidium  albicans  and 
saccharomyces  fungi,  found  in  the  sputum  in  such  cases. 

PROTOZOA 

Amebae 

In  addition  to  the  dysenteric  amebae  which  have  been  described, 
amebae  differing  slightly  in  certain  characteristics  from  the  dysenteric 
variety  have  been  reported.  They  are  said  to  give  rise  to  no  symptoms 
or  at  times  to  slight  diarrhea.  Musgrave  is  skeptical  as  regards  the 
existence  of  non-pathogenic  amebae. 

Sporozoa 

Coccidia  are  occasionally  found  in  the  stools.  These  are  egg  shaped, 
provided  with  a  thin  shell,  are  about  0.02  mm.  long,  containing  in  the 
interior  a  large  number  of  nuclei,  usually  arranged  in  groups.  They  do 
not  seem  to  have  a  pathologic  bearing. 

Internal  Psorospermiasis 

Psorosperms  have  been  found  in  the  liver,  spleen,  kidneys,  and  ileum, 
producing  a  disease  similar  to  that  in  rabbits.  One  patient,  notably 
referred  to  by  Osler,^  was  thought  to  be  suffering  from  typhoid  fever. 
The  patient  had  diarrhea  and  enlarged  liver  and  spleen.  Masses 
resembling  tubercles  in  the  liver,  spleen,  and  ileum  were  found  to  contain 
coccidia. 

Infusoria 

Cercomonas  intestinalis  is  pear  shaped,  has  a  distinct  nucleus,  and 
eight  flagellae.     The  head  tapers  obliquely  and  has  a  depression  (Fig.  366). 

*  Philippine  Jour,  of  Sci.,  July,  1910. 

*  Prac.  Med.,  1906. 

920 


INTESTINAL   PARASITES 


921 


It  is  believed  that  this  organism  is  liable  to  prolong  existing  catarrhal 
affection  of  the  intestines. 


Fig.  366. — Cercomonas   intestinalis:  A,  larger,    B,   smaller,   variety    (Davaine). 

Trichomonas  intestinalis  is  distinguished  from  the  former  by  its 
greater  size  and  the  row  of  fine  cilia  on  its  periphery  (Fig.  367).  In 
fresh  dejecta  it  shows  active  movements.  Zunker^  reports  it  in  mushy 
dejecta^  of  yellowish-brown  color  and  putrid  odor.     Dalley^  reports  a  case 


Fig.  367. — Trichomonas  intestinalis    (after    Zunker). 

of  gangrene  of  the  lung  in  which  traumatism  of  the  chest  was  a  factor. 
Numberous  trichomonas  actively  motile  were  found  in  the  sputum. 

Balantidium  (Paramoecium)  Coli. — The  body  is  oval  shaped,  measur- 
ing from  0.07  to  0.1  mm.  in  length,  by  0.05  to  0.07  mm.  in  breadth  (Fig. 
368).     The  anterior  end  is  slightly   truncated,  with  a  short  peristome, 
generally  funnel  shaped,  and  opens  externally  near  the 
anterior  pole.     When  feeding  it  opens  out  and  broadens, 
so  one  can  see  it  is  a  mouth  which  leads  to  a  gullet  and 
not  a  simple  furrow.     The  left  border  has  long  cilia,  while 
the  rest  of  the  mouth  is  destitute  of  them.     The  surface 
of  the  cortical  layer  is  surrounded  by  a  cuticle  covered 
with  cilia.     The  interior  structure  consists  of  granular  sub- 
stance.    It  contains  a  nucleus  and  contractile  vacuoles. 

Fat  and  starch  granules  and,  occasionally,  red  and  white 
corpuscles  may  be  found  within  'the  granular  substance. 
The  posterior  end  is  rounded  and  contains  the  anus.  Par- 
ticles may  be  observed  to  pass  from  it.  The  parasite  can 
change  its  shape  and  possesses  both  forward  and  rotary  motion 
production  occurs  by  division,  budding,  and  conjugation. 

The  balantidium  is  a  parasite  of  the  colon  and  cecum  of  the  hog.  Human 
infection  probably  occurs  most  frequently  through  the  infusorium  entering 
its  host  in  the  encapsulated  state.  When  hog  feces  are  dried  and  broken 
up,  the  encysted  forms  are  scattered  about  and  come  in  contact  with  the 
food  or  drinking-water.    The  parasite  has  been  found  in  the  city  of  London 

1  Deuts.  Zeits.  f.  Praktish.  Medicin,  1878,  No.  i. 

2 Lynch  (N.  Y.  Med.  Jour.,  May  i,  1915)  reports  mild  enteritis  with  intermittent 
diarrhea.  Infection  occurs  from  active  forms  from  dejecta  of  rabbits  and  encysted 
forms  from  human  beings.  Infection  per  orem  or  rectum.  Dysenteric  diarrhea  may 
occur  (Rhamy,  Jour.  Amer.  Med.  Assoc,  April  15,  19 16)  with  death  even. 

3  Jour.  Amer.  Med.  .Assoc,  Oct.  15,  1910. 


Fig.  368.— Ba- 
lantidium coli 
(Malmsten). 


Re- 


922 


DISEASES   OF  THE   STOMACH  AND  INTESTINES 


in  the  drinking-water.  The  disease  frequently  occurs  after  the  preparation 
of  sausage  or  the  ingestion  of  uncooked  sausage-meat.  Malmsten  first 
described  the  disease  in  1857. 


Fig.  369. — Balantidium  cbli:  Parasite  more  liighly  magnified,  showing  flagella  (Strong). 

Musgrave  has  written  on  the  subject,  and  for  the  most  complete  de- 
scription the  reader  should  refer  to  R.  P.  Strong's*  article,  "The  Clinical 


Fig.  370. — Balantidium  coli:  A  parasite  passing  through  the  walls  of  a  gland  of 
Lieberkiihn,  rupturing  the  basement  membrane.  The  parasite  shows  the  striation 
referred  to  in  the  text  (Strong). 

and  Pathologic  Significance  of  Balantidium  Coli."  He  tabulates  117 
cases.  Brewer^  reports  a  case  occurring  in  a  child  aged  five  years  in  the 
Philippines.     Other  intestinal  parasites  were  also  present. 

^  Bureau  of  Government  Laboratories,  Manila,  Dec,,  1904,  No.  26. 
*  N.  Y.  Med.  Jour.,  June  18,  1910. 


INTESTINAL  PARASITES 


923 


The  balantidia  frequently  exist  alone,  though  sometimes  other  para- 
sites, such  as  Bothriocephalus  latus,  Ascaris  lumbricoides,  Trichocephalus 
dispar,  etc.,  may  be  associated.     Bowman^  reports  cases. 

Harlow  Brooks^  found  balantidia  the  cause  of  an  epidemic  of  diarrhea 
among  the  orang-outangs  in  the  New  York  Zoological  Park.  The 
lesions  found  in  human  beings  seem  to  be  an  ulcerative  colitis  (Figs. 
369-371),  with  the  infection  in  the  large  intestine.  In  some  cases  there 
were  swelling  of  the  lymphatics  of  the  mesentery  and  mesocoHc  glands 
and  chronic  adhesive  peritonitis.  Pulmonary,  cardiac,  renal,  and  cerebral 
complications  may  occur. 

Symptoms. — The  presence  of  Balantidia  coli  in  the  stools  is  usually 
associated  with  diarrhea;  the  feces  are  liquid,  often  contain  mucus,  some- 
times undigested  food,  and  frequently  blood.     Diarrhea    is   persistent 


Fig.  371. — Balantidium  coli.  inc  cari\  iusiuu>  of  the  mucosa,  consisting  of  des- 
quamation of  epithelial  cells  of  the  glands,  round-celled  infiltration,  etc.  About  a 
dozen  parasites  may  be  counted  in  this  field  (Strong). 


until  treatment  is  directed  against  the  parasite.  Colic  is  frequent,  nausea 
and  vomiting  may  occur.  The  abdomen  may  be  swollen.  It  is  often 
painful  on  pressure  along  the  colon,  and  on  palpation  the  latter  may 
feel  thickened.     Tenesmus  is  common. 

In  chronic  cases  there  are  weakness,  exhaustion,  and  emaciation; 
more  or  less  anemia  and  edema  of  the  feet  and  ankles. 

In  the  fresh  stools  the  balantidia  move  about  rapidly,  but  die  in  from 
one-half  hour  to  two  hours  after  the  dejecta  have  been  passed. 

Only  two  cases  are  reported  in  children;  25  per  cent,  of  cases  give  the 
history  of  association  with  or  caring  for  pigs  or  having  eaten  or  prepared 
fresh  sausage. 

Eosinophilia  is  present  locally  in  the  intestines  and  also  in  the  blood. 
The  temperature  may  be  subnormal  or  at  times  of  considerable  height. 

'  Jour.  Amer.  Med.  Assoc,  Dec.  2,  1911. 

2  N.  Y.  University  Bull,  of  Med.  Sci.,  Jan.,  1902. 


924  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

The  disease  has  been  found  in  Germany,  Sweden,  Russia,  France, 
the  United  States,  and  the  Philippines.  Balantidia  probably  occur  more 
frequently  than  we  suppose. 

The  mortality  was  30  per  cent.,  but  depended  somewhat  on  the 
presence  of  other  diseases  which  were  associated  in  many  of  the  fatal  cases 
reported.  In  ^^  per  cent,  there  were  cures,  and  improvement  in  the  other 
cases. 

Treatment.^ — The  following  solutions  for  topical  irrigations  or  enemata 
have  been  suggested: 

Ems'  salt,  by  water  enemata,  15  grains  (i.o)  are  added  to  1500  c.c. 
{i}4  quarts)  of  water, followed  by  quinin  enemata,  i  quart  (liter)  of  1 1750 
or  I  :  500  strength. 

Others  suggest  calomel,  2  grains  (o.i)  t.i.d.  for  two  days  only,  or 
naphthalin,  5  grains  (0.3)  t.i.d.,  daily  by  mouth,  with  tannic  acid, 
I  dram  to  i  pint  (4.0-500  c.c.)  of  water,  by  injection,  every  day. 

Acetic  acid  enemata — acetic  acid,  50  grains  (3.3)  to  2  quarts  (liters) 
of  water  at  37°C. — once  or  twice  a  day,  with  tannic  acid  5  grains  (0.3) 
t.i.d.,  by  mouth,  proved  useful  in  some  cases. 

Another  combination  is  salicylic  acid,  15  grains  (i.o),  and  sodium 
sulphate,  l-^  ounce  (16.0),  morning  and  night,  by  mouth,  with  enemata 
twice  a  day  of  salicylic  acid.(i  :iooo),  or  salol,  by  mouth,  5  grains  (0.3), 
four  or  five  times  a  day,  with  salicylic  acid  (i  :iooo),  or  boracic  acid  ene- 
mata I  dram  (4.0)  to  the  quart  (liter)  of  water,  are  suggested. 

Sodium  bicarbonate  (2  per  cent.)  enemata,  followed  by  a  salicylic 
acid  (i  :  2000-1  :  1000)  enema,  with  salol,  5  grains  (0.3),  and  tannalbin, 
5  to  10  grains  (0.3-0.6),  by  mouth,  each  several  times  a  day,  have  given 
good  results. 

Thymol  (i  :  2500),  acetozone  (i  :  1000),  quinin  bisulphate  (i  :  500), 
administered  by  enema  or  irrigation,  as  in  dysentery,  with  the  use  of  salol 
and  tannin  preparations  by  mouth,  are  valuable. 

One  might  also  administer  small  quantities  of  acetozone  (i  :  1000) 
by  mouth. 

VERMES 

Cestodes  (Tapeworms) ;  Hydatid  Disease. — The  adult  parasites  live 
in  the  small  intestine  of  man;  the  larval  forms,  in  the  muscles  and  other 
organs. 

The  most  important  varieties  of  tapeworms  found  in  human  beings  are 
the  Taenia  solium.  Taenia  mediocanellata,  and  the  Bothriocephalus  latus. 

The  symptoms  produced  by  these  varieties  of  tapeworms  are  about 
identical,  except  in  the  case  of  the  bothriocephalus,  which  at  times  gives 
special  symptoms. 

The  parasites  are  found  at  all  ages,  are  not  uncommon  in  children, 
and  occasionally  are  found  in  sucklings.  They  may  cause  no  disturbance, 
and  one  may  only  learn  of  their  presence  by  noting  segments  of  the  tenia 
in  the  dejecta.     Eosinophilia  is  present. 

In  other  cases  there  may  be  general  as  well  as  intestinal  disturbances. 

There  may  be  pressure  in  the  pit  of  the  stomach,  abdominal  pains, 

^  For  Trichomonas. — Ipecac,  emetin  by  hypo,  and  thymol,  with  enteroclysis  with 
I  per  cent,  bexametbylenamin  solution  and  s  per  cent,  argyrol  applied  to  rectal  ulcers. 


INTESTINAL  PARASITES  925 

ravenous  appetite  (bulimia),  nausea,  at  times  loss  of  appetite,  occa- 
sionally vomiting.  Diarrhea  is  sometimes  present  or  there  may  be 
constipation. 

In  women  and  nervous  patients  we  may  see  mental  depression  and 
even  hypochondria.  There  may  be  dizziness,  headache,  fainting  spells, 
chorea,  convulsions,  and  even  epileptic  attacks.  Some  patients  may 
emaciate,  feel  weak,  and  suffer  from  palpitation. 

The  hothriocephalus  may  cause  a  severe  and  even  fatal  anemia  (per- 
nicious), with  poikilocytosis  and  nucleated  red  blood-corpuscles;  and  with 
it  there  may  be  edema  of  the  feet  and  eyelids  and  hemorrhages  from  the 
mucous  membranes. 

The  metabolic  products  of  this  worm  probably  have  a  hemolytic 
action. 

The  diagnosis  can  only  be  made  by  discovery  of  the  segments  of  the 
parasites  or  their  eggs  in  the  stools. 

General  Description  of  the  Tapeworm. — It  has  a  scolex  or  head,  which 
may  live  for  years  even  when  detached  from  the  rest  of  the  body,  an  ob- 
long neck,  and  detachable  segments  (proglottides).  These  vary  in  size 
and  shape  and  possess  the  power  of  motion.  The  worm  is  flat  and  devoid 
of  mouth  or  intestines.  It  grows  by  alternate  generation  through  ger- 
mination of  a  pear-shaped  primary  host  (head),  and  remains  united  to  the 
latter  for  a  time  as  a  colony  of  band-like  shape.  Each  segment  forms  a 
sexually  active  individual.  The  proglottides  gradually  increase  in  size 
as  they  become  more  distant  from  the  head,  and  then  diminish  again 
toward  the  extremity.  The  tapeworm  is  an  hermaphrodite.  On  its 
head  are  four  sucking  disks,  by  which  it  attaches  itself  to  the  mucosa  of 
the  intestines.  By  means  of  pores  it  derives  its  nourishment  from  the 
chyme. 

The  older  proglottides  contain  many  fructified  eggs.  These  are 
emptied  at  intervals  into  the  intestinal  canal  and  appear  in  the  dejecta. 
The  ovum  contains  an  embryo,  which  requires  for  its  development  an 
intermediary  host.  After  reaching  the  stomach  the  envelope  is  dissolved 
by  the  gastric  juice.  The  embryo  is  set  free  and  finds  its  way  by  the 
lymphatics  or  blood-vessels  to  some  place  (usually  the  muscles)  where  it 
settles.  It  here  surrounds  itself  with  a  sac,  which  may  later  be  surrounded 
by  a  calcareous  deposit.  In  this  condition  it  is  called  a  cysticercus  or 
measle.  When  the  measle  reaches  the  stomach  of  a  new  host  it  opens,  and 
its  scolex  enters  into  the  small  intestine,  where  it  develops  into  a  full- 
grown  tapeworm. 

Tcenia  Solium. — Armed  tapeworm  or  pork  tapeworm.  This  is  not 
common  to  North  America,  but  more  frequent  in  Europe  and  Asia. 
When  mature  it  is  from  6  to  12  feet  (2-4  meters)  or  more  long.  The  head 
is  smaller  than  the  head  of  a  pin,  spheric,  and  provided  with  four  sucking 
disks,  in  the  middle  of  which  is  the  rostellum  and  a  double  row  of  booklets, 
from  twenty-four  to  twenty-six  in  number,  and  hence  is  called  the  armed 
tapeworm  (Fig.  372). 

The  neck  is  narrow  and  thread-like,  nearly  i  inch  long.  The  body  is 
divided  into  segments,  which  possess  both  male  and  female  generative 
organs,  and  at  about  the  four  hundred  and  fiftieth  thev  become  mature 


926 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


and  contain  ripe  ova.  The  segments  are  about  i  cm.  in  length  and 
from  7  to  8  mm.  wide.  The  worm  attains  its  full  growth  in  about  three 
to  three  and  a  half  months,  about  which  time  the  segments  are  con- 
tinuously shed  and  appear  in  the  stool.  The  uterus  forms  a  straight 
median  tube  in  each  segment,  giving  off  five  to  seven  branches  on  each 
side.  The  branches  are  undivided  at  first,  but  finally  ramify  as  a  tuft 
(Fig.  373). 

The  eggs  are  rounded  and  provided  with 
a  thick  shell  (Fig.  374). 

Rarely  the  cysticerci  (measles)  are  found 
in  man,  as  in  the  muscles,  brain,  eye,  and 
skin. 


Fig.  372. — Head  of  Taenia  solium, 
rostellum  with  hooks;  suckers  (Mosler 
and  Peiper). 


Fig.  373. — Mature  segments  of  Taenia 
solium;  proglottides;  uterus  and  branches 
(Mosler  and  Peiper). 


In  the  muscular  system  they  cause  pain,  numbness,  weakness,  and 
symptoms  a  little  like  peripheral  neuritis.  In  the  ventricles  of  the  brain 
irritative  symptoms  may  result.  In  one  case  diabetic  symptoms  were 
reported.  They  can  be  recognized  in  the  eye.  Taenia  solium  was  formerly 
believed  to  exist  alone,  but  several  have  been  found  together. 

Tcenia  saginata,  or  mediocanellata,  the  unarmed  or  beef  tapeworm. 


Fig.  374. — Eggs  of  Taenia  solium,  showing  thick  shell  (Mosler  and  Peiper). 

This  is  the  most  common  form  seen  in  America  as  well  as  abroad. 
It  is  longer,  thicker,  and  wider  than  the  Taenia  solium.  It  may  attain  a 
length  of  15  to  20  feet  (approximately  4>^  to  6  meters)  or  more.  The 
head  measures  over  2  mm.  in  breadth,  has  four  large  sucking  disks,  but  no 
booklets  and  no  rostellum  (Fig.  375).     It  is  square  shaped. 

The  ripe  segments  are  from  17  to  18  mm.  in  length  and  from  8  to  10 
mm.  in  breadth.  The  uterus  consists  of  a  median  stem,  with  from  about 
twenty  to  thirty-five  lateral  branches  (Fig.  376).     Malformations  of  the 


INTESTINAL  PARASITES 


927 


Taenia  saginata  have  been  reported.     MacCallun^  refers  to  an  interesting 
case  showing  lateral  spUtting  of  the  segments. 

The  ova  are  larger  and  the  shell  thicker,  and  possibly  slightly  more 
elliptic,  but  the  two  forms  are  difficult  to  distinguish  by  their  ova.  The 
measles  (cysticerci)  occur  in  beef  and  are  smaller  than  those  of  the  Taenia 
solium.  Human  beings  acquire  this  worm  by  the  consumption  of  raw 
beef. 


Fig.  377. — Bothriocephalus  latus:  c,  a, 
Head;  b,  neck  (Blanchard). 


Fig.  375. — Scolex   of     Taenia     saginata 
(Mosler  and  Peiper). 


Fig.  376. — Segments  of  Taenia  saginata 
(Mosler  and  Peiper). 


Fig.  378-- 


-Botliriocephalus  latus  (Eich- 
horst). 


Bothriocephalus  Latus  (Taenia  Lata,  or  Pig  Head). — This  is  found 
in  certain  districts  bordering  on  the  Baltic  Sea,  in  Holland,  Switzerland, 
and  Japan.  A  few  cases  have  occurred  in  the  United  States,  believed 
generally  to  have  been  imported. 

The  parasite  is  large  and  long,  measuring  25  to  30  feet  or,  more  ap- 
proximately, 73-^  to  9  meters. 

^Med.  Rec,  Mar.  23,  1912. 


928  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

The  head  is  elongated,  almond  shaped,  being  about  2  mm.  long  and 
I  mm.  broad;  it  has  two  grooves,  probably  suckers,  on  its  flat  surface 
(Fig.  377). 

It  has  no  hooklets.  The  neck  is  narrow  and  short,  about  2  cm.  in 
length,  and  passes  at  once  into  the  body  segment.  The  body  is  thin  and 
flat  (Fig.  378).  The  full-grown  proglottides  are  nearly  square  and  show 
the  sexual  organs  in  the  center. 

The  uterus  presents  as  a  median  dark  line,  with  four  to  six  lateral 
branches,  looking  like  a  star  or  rosette.  The  eggs  are  oval,  round,  with  a 
thin  membrane  and  a  lid  (Fig.  379).  They  measure  0.07  mm.  long  and 
0.04  mm.  in  width.  The  larvae  develop  in  the  peritoneum  and  muscles  of 
pike  especially,  and  of  fish  such  as  the  turbot,  perch,  and  trout.  Infection 
occurs  through  eating  insufficiently  cooked  fish. 

Taenia  lata  occur  in  the  small  intestine  of  men  and  rarely  in  dogs. 
A  severe  and  even  fatal  form  of  anemia  may  result  from  this  worm. 

There  are  a  few  rare  forms  of  tapeworms  occasionally  found  in  human 
beings. 

Tcenia  nana  (Hymenolepsis  nana)  occurs  chiefly  in  Italy,  occasionally 
in  Egypt.  It  is  the  smallest  tapeworm  found  in  man,  measuring  10  to 
15  mm.  long,  and  may  have  nearly  two  hundred  segments.     The  head 

has  four  sucking  disks,  a  rostellum,  and 
about  twenty-four  hooklets  in  a  single 
row.  Proglottides  are  short  and  broad. 
It  is  found  more  frequently  in  children, 
and  occurs  in  large  numbers  in  the  small 
intestine. 

Nervous  disturbances,  fainting  spells, 
Fig.  379-— Eggs  of  Bothriocephalus  and  even  epileptiform  attacks  are  pro- 
la  tus  (Mosler  and  Peiper).  j        j  ^i        iL 
*^                duced  thereby. 

The  Davainea  Madagascariensis  (Taenia  Madagascariensis)  is  a  rare 
form  of  this  worm. 

Taenia  cucumerina  (EUiptica,  or  Dipylidium  Caninum). — This  is 
small,  of  cucumber  shape,  occurs  frequently  in  the  intestines  of  the  dog, 
and  has  been  found  in  small  children.  The  larvae  develop  in  the  lice  and 
fleas  of  the  dog.     The  worm  is  10  to  40  cm.  long  and  about  3  mm.  wide. 

Tania  Flavopundata  (Hymenolepsis  Diminuta). — This  has  been  met 
with  in  about  12  cases.  The  worm  is  2  to  6  cm.  long  and  about  3  mm. 
wide.  Its  head  is  small,  club  shaped,  and  provided  with  sucking  disks. 
It  is  common  in  rats.     The  larvae 'develop  in  Lepidoptera  and  in  beetles. 

Bothriocephalus  Cordatus. — This  tapeworm  resembles  the  Bothrio- 
cephalus latus,  except  that  it  is  shorter  and  the  head  merges  into  the 
proglottides  without  an  intervening  neck.  It  occurs  in  the  intestines  of 
men  and  dogs  in  Greenland. 

Other  types  of  tapeworms  occur,  but  they  are  excessively  rare  and  not 
found  in  Europe  or  America. 

Echinococci  are  the  larvae  of  the  Taenia  echinococcus  of  the  "dog.  The 
latter  is  a  tiny  cestode  4  or  5  mm.  long,  consisting  of  three  or  four  segments, 
of  which  the  terminal  one  alone  is  mature.  The  head  is  small,  provided 
with  four  sucking  disks,  and  a  rostellum  with  a  double  row  of  hooklets. 


INTESTINAL    PARASITES  929 

As  a  result  of  the  ingestion  of  these  parasites,  cysts  develop  in  various 
parts  of  the  human  organism,  as  in  the  liver,  muscles,  etc.  These  cysts 
contain  scolices,  the  head  of  the  taenia  presenting  four  sucking  disks  and  a 
circle  of  hooklets. 

Cysts  have  been  passed  per  rectum.  The  disease  is  common  to  Ice- 
land, not  uncommon  in  Europe,  but  rare  in  this  country.  The  reader  is 
referred  to  Echinococcus  Disease  in  any  work  on  Practice  of  Medicine. 

Treatment  of  Tapeworms. — To  escape  infection  avoid  raw  or  medium- 
done  meats,  pork,  and  fish.  One  should  not  trust  to  meat  inspection 
alone.  Thorough  cooking  of  the  meat  is  the  only  guarantee  of  extinction 
of  the  cysticerci.  All  worms  or  fragments  removed  should  be  destroyed 
by  burning,  and  if  one  handles  the  proglottides  or  ova,  the  hands  should 
immediately  be  disinfected;  also  the  stools. 

For  about  two  days  before  administering  a  vermifuge  the  patient 
should  be  kept  on  a  scanty  diet,  consisting  of  broths,  soups  or  milk,  with 
a  few  crackers.  The  night  before,  no  food;  and  in  the  morning  a  cup  of 
tea  or  coffee,  followed  in  about  an  hour  by  the  vermifuge. 

Calomel,  5  grains  (0.3),  castor  oil,  3-^  to  i  ounce  (15.0-30.0),  or  a 
saline  cathartic  should  be  given  daily  for  a  couple  of  days  previously. 

Male  fern  is  considered  quite  efficient. 

Extract  of  filix  mas,  ethereal,  ij^  to  2}^  drams  (6.0-10.0),  mixed  with 
simple  syrup;  follow  in  a  couple  of  hours  by  a  saline  cathartic  or  castor  oil. 

The  following  have  also  been  suggested:  Oleoresin  aspidii  (male 
fern),  >^  to  i  dram  (2.0-4.0),  in  capsules,  coated  with  keratin;  a  few  hours 
later  castor  oil,  i  ounce  (30.0). 

Filicic  acid  (filmaron),  an  amorphous  principle  from  root  of  male 
fern,  insoluble  in  water.  It  should  not  be  administered  in  fatty  oils  or 
alcohol,  as  they  dissolve  it  and  it  is  toxic.  Give  in  capsules,  yj.^  to  15 
grains  (0.5-1.0);  follow  by  a  saline  purgative  (not  castor  oil). 

Pomegranate  root  is  efficient,  given  as  an  infusion  of  the  bark;  3  ounces 
are  macerated  in  10  ounces  of  water  and  then  reduced  to  one-half  by 
evaporation.  The  entire  quantity  is  taken  in  divided  doses  within  an 
hour  or  more.     It  is  effective,  though  sometimes  producing  colic. 

The  active  principle  of  the  root,  pelletierin,  4  to  7^2  grains  (0.25- 
0.5),  in  sweetened  water,  to  which  tannin,  5  grains  (0.3),  can  be  added 
may  be  given  as  a  substitute.  These  remedies  are  followed  in  a  couple  of 
hours  by  a  purge.  Pelletierin  tannate  can  be  secured  and  given  in  the 
same  dose. 

Pumpkin  seeds  (Semina  cucurbitae),  3  or  4  ounces  (90.0-125.0),  should 
be  bruised  and  macerated  for  twelve  to  fourteen  hours.;  then  mixed  with 
a  little  grape-sugar,  diluted  with  milk,  i  pint  (500  c.c),  and  take  in  two 
doses  about  half  an  hour  apart;  then  follow  in  two  hours  by  castor  oil. 

Turpentine,  Oleum  terebinthinae  (spirits  of  turpentine),  i  ounce  (30.0), 
in  honey  or  with  sugar,  follow  with  a  glass  or  two  of  milk;  and  two  hours 
later  a  cathartic. 

I  have  found  pine-needle  oil  (Gardner's),  i  to  2  drams  (4.0-8.0),  also 
efficacious. 

Cusso  (kousso). — Cusso  pulv.,  ^^  ounce  (16.0)  with  mel  depuratum 
(honey),  3-^  ounce  (16.0),  is  useful. 
59 


930  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Or  cusso  can  be  mixed  with  sugar,  water,  or  lemonade,  and  taken  in 
divided  doses  within  an  hour.  Though  cusso  is  cathartic,  it  is  preferable 
to  follow  in  two  hours  with  a  dose  of  castor  oil. 

Kamala. — Pulv.  kamala,  i  to  2  drams  (4.0-8.0),  suspended  in  syrup 
or  in  wine.  This  preparation  is  purgative  and  may  cause  griping,  nausea, 
and  vomiting.  The  dose  should  be  distributed  over  an  hour.  Castor  oil 
may  be  given  later. 

Cocoanut  has  been  recommended  as  a  vermifuge;  the  milk  and  al- 
bumin of  an  entire  nut  should  be  taken  within  an  hour. 

Naphthalin,  in  capsules,  10  to  30  grains  (0.6-2.0),  in  divided  doses, 
within  a  few  hours,  is  another  vermifuge. 

Salol,  45  grains  (3.0),  in  capsules,  in  divided  doses,  has  been  recom- 
mended. 

A  combination  of  these  remedies  is  often  effective.  Thus:  take  }4 
ounce  (16.0)  of  an  infusion  of  pomegranate  seeds;  pumpkin  seeds,  i  ounce 
(30.0);  pulverized  ergot,  i  dram  (4.0),  and  boiling  water  10  ounces  (300 
c.c.  approximately).  Make  an  emulsion  of  male  fern — i  dram  (4.0) 
ethereal  extract  with  acacia  powder.  Mix  the  emulsion  and  infusion  and 
take  fasting  at  9  a.  m.  Follow  a  couple  of  hours  later  with  castor  oil  or  a 
saline  cathartic. 

Osier  recommends  the  addition  of  croton  oil,  2  minims  (0.118),  to  the 
above,  but  I  think  this  rather  too  active  treatment.  Male  fern,  pumpkin 
seed,  pomegranate,  and  turpentine  are  the  best  remedies. 

About  two  hours  after  the  vermifuge  a  cathartic,  such  as  citrate  of 
magnesia,  i  to  2  drams  (4.0-8.0),  or  magnesium  sulphate,  larger  doses, 
or  some  other  saline  cathartic,  or  castor  oil,  i  to  2  ounces  (30.0-60.0), 
should  be  given. 

The  head  of  the  tapeworm  should  be  looked  for,  as  the  parasite  will 
regrow  if  this  is  not  removed.  In  some  cases  this  is  difl&cult  to  find. 
Children  require  proportionately  smaller  doses,  according  to  their  age. 
Care  must  be  exercised  with  patients  who  are  debilitated,  recently  con- 
valescent from  typhoid,  or  have  severe  intestinal  disorders.  It  may  be 
necessary  to  postpone  treatment. 

Trematodes  (Fluke  Worms) ;  Distomiasis. — Flukes  are  found  in  the 
lungs,  liver,  small  intestine,  and  in  the  blood;  in  the  latter  case  affecting 
chiefly  the  urinary  system  and  the  rectum. 

The  trematodes  are  solid  worms  of  leaf  or  tongue  shape.  They 
possess  a  clinging  apparatus  in  the  form  of  oral  and  ventral  sucking  cups, 
which  vary  in  number.  Sometimes  they  also  have  hook  or  clasp-like 
projections.  The  intestinal  canal  is  without  an  anus  and  is  split  like  a 
fork.     They  are  generally  hermaphroditic. 

Flukes  are  found  in  China,  Japan,  India,  Egypt,  Arabia,  and  Persia, 
and  imported  cases  have  been  found  in  Canada  and  the  United  States. 

They  have  been  found  in  the  cat,  dog,  and  hog  in  this  country. 

Five  species  of  liver  fluke  are  known  to  occur  in  man.  The  Distoma 
conjunctum,  the  Indian  liver  fluke,  usually  described,  the  Distoma  lancea- 
tum  (lancet  fluke),  and  the  Distoma  sinensis  are  the  most  frequent 
occurring  in  the  liver,  the  last  being  most  important. 

The  Fasciola  hepatica,  common  to  ruminants,  and  the  Opisthorchis 


INTESTINAL   PARASITES 


931 


(Distoma)  felineus,  occurring  in  Prussia  and  Siberia,  and  found  in  cats  in 
Nebraska,  are  the  other  varieties. 

In  general,  we  may  say  the  Hver  fluke  is  of  leaf  shape.     It  may  vary 
in  length  from  10  to  20  mm.  by  2  to  5  to  10  mm.  broad.     The  cephalic  end 


Fig.  380. — Distoma  hepaticum,  with  male  and  female  sexual  apparatus;  X  2^ 

(Leuckart). 

projects  like  a  beak  and  has  a  small  cup-like  sucker,  in  which  lies  the 
mouth.  Behind  this,  on  the  ventral  surface,  is  a  second  cup,  and  between 
the  two  is  a  special  orifice.  The  uterus  appears  as  a  convoluted  bag 
behind  the  posterior  sucker.  On  each  side 
of  the  body  are  the  ovisacs  and  the  branched 
testicular  canals  (Fig.  380). 

The  eggs  are  oval,  25  to  30  ju  long  by  15 
to  1 7  /i  broad,  of  brown  color,  with  a  sharply 
defined  operculum  (lid)  (Fig.  381). 

The  Distoma  lanceolatum,  another  variety 
of  liver  fluke,  has  a  lancet  shape  and  the 
head  is  not  especially  marked  off  from  the 
body  (Fig.  382),  The  eggs  are  rather  small, 
0.04  mm.  long  (Fig.  383). 

Young  children  suffer  more  frequently 
from  liver  fluke;  sometimes  whole  families 
or  villages  are  attacked.  Fig.  381.— Eggs  of  Distoma 

There  is  an  irregular  diarrhea;  there  may  hepaticum  and  Distoma  lanceo- 
,,,,,      „,       ,.  ,  -^    latum,      moderately      magnified 

or   may  not  be  blood.    The  hver  enlarges.   (Heller). 

There  are  often  pain  and  an  intermittent 

jaundice,  but  not  much  fever.     Anasarca  and   ascites  come  on  later. 

The  ova  of  the  parasite  are  found  in  the  stool. 

Intestinal  Distomiasis. — In  India  the  Distoma  fasciolopsis  has  been 

found  in  a  number  of  cases  in  the  small  intestine,  with  diarrheal  symptoms. 


Fig.  382. — Distoma  lanceolatum  with  its  inner  organs;  X  10  (Leuckart). 

Hemic  Distomiasis;  Distoma  Hcemaiobiiim;  Bilharziasis;  Schistosoma 
Hcematobium;  Bilharzia  Hcematobia. — Endemic  hematuria,  particularly 
in  Egypt,  had  been  known  for  many  years,  when  in  1851  Bilharz  dis- 


932 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


covered  the  parasite  of  the  disease.  The  blood  fluke  prevails  in  South 
Africa  (the  Transvaal);  in  North  Africa,  especially  in  Egypt;  in  Arabia, 
Persia,  and  the  west  coast  of  India.     It  is  prevalent  in  Japan.    It  has 


Fig.  383-- 


of  Distoma  lanceolatum  shortly  after  the  formation  of  a  shell;  X  400 
(Leuckart). 


been  observed  in  Porto  Rico  and  in  the  PhiUppines.  It  has  been  reported 
104  times  on  the  Isthmus  of  Panama  according  to  statistical  records  from 
the  Chief  Sanitary  OflSce  from  1904-1909  inclusive.     It  has  also  occurred 

in  Antigua,  Trinidad,  Demarara, 
Barbadoes.  Jamaica,  and  Dutch 
Guiana. 

Brayton^  reports  several  interest- 
ing cases  from  the  Ancon  Hospital  on 
the  Isthmus.  The  disease  is  rare  in 
the  United  States,  only  seven  cases 
having  been  reported.  In  addition, 
seven  cases  occurred  among  the  Boers 
who  were  on  exhibition  in  this  country 
after  the  African  War. 

The  first  case  of  rectal  infection 
reported  in  the  United  States  was  in 
a  German,  who  evidently  contracted 
the  disease  in  Brazil  and  who  was 


Fig.  384. — Male  and  female  of  Bilhar- 
zia  hsematobia  (Loos). 


Fig.  385. — Eggs  of  Distomum  haema- 
tobium (Bilharzia  hsematobia),  length,  0.12 
mm.;  breadth,  0.05  mm. :  a.  Egg  with  lateral 
spine;  b,  egg  with  terminal  spine;  X  15° 
(after  Bilharz). 


treated  at  the  German  Hospital.  He  suffered  from  mixed  infection — 
Strongyloides  intestinalis,  Trichocephalus,  and  Schistosoma  haematobium, 
reported  by  L.  Blumgart,^  of  New  York. 

'  Jour.  Amer.  Med.  Assoc,  April  30,  1910. 
^  Med.  Rec,  April  6,  1907. 


INTESTINAL   PARASITES 


933 


The  Schistosoma  has  separate  sexes  and  carries  the  female  in  a  gyneco- 
phorous  canal.  The  male  is  from  12  to  14  mm.  long.  Its  body  has 
ciliated  warts  on  the  integument,  but  otherwise  is  smooth,  and  in  the  pos- 
terior portion  is  rolled  up  into  a  tube,  which  serves  for  the  reception  of 
the  female  (Fig.  384). 

There  is  a  sucker  at  the  anterior  end  and  a  second  one  posterior  to 
it  on  the  ventral  surface.  The  female  is  from  16  to  18  mm.  long  and 
nearly  cylindric.  The  eggs  have  a  terminal  or  lateral  spine  (Fig.  385). 
The  trematode  is  most  abundant  in  the  blood  of  the  portal  system,  while 
the  ova  lodge  in  the  capillaries,  especially  of  the  bladder,  urinary  organs, 
rectum,  and  lungs.  In  the  stools  of  the  case  reported  the  spine  was  placed 
laterally  on  the  ova. 

Infection  is  now  considered  to  take  place  in  two  ways — either  by  the 
gastro-intestinal  tract,  through  infected  food  or  water,  or  through  the 
skin  by  bathing  in  infected  streams. 

The  parasite  reaches  the  portal  system,  where  it  develops.  The  males, 
bearing  the  females,  creep  to  various  parts,  particularly  the  bladder  and 
rectum.  The  eggs  are  laid  in  the  tissues,  but  wander  like  other  sharp 
foreign  bodies,  and  escape  with  the  urine  and  feces.  The  eggs  in  the  tissues 
cause  irritation,  fibroid  changes,  and  papillomatainthe  bladder  and  rectum. 
Hematuria  and  bladder  irritation,  chronic  cystitis,  tenesmus,  mucus  and 
blood  in  the  stools,  ulcerative  proctitis,  calculi  in  the  kidney  and  bladder, 
peri-urethral  abscess  and  perineal  fistula,  vaginitis,  inflammation  of  the 
ureters  and  seminal  vesicles  may  all  occur.  Bilharzial  colitis  has  been 
reported.  In  the  lungs  the  blocking  of  blood-vessels  from  the  ova  and 
the  surrounding  infiltration  give  rise  to  deposits  which  may  be  mistaken 
for  tuberculosis.  Cirrhosis  of  the  liver  and  biliary  calculi  may  be  caused 
by  the  presence  of  the  parasite. 

Anemia  is  present  and  eosinophilia  is  quite  marked. 

In  1904  there  was  described  a  new  blood  fluke.  Schistosoma  Cattoi, 
or  Japanicum,  found  in  Japan.  It  lives  chiefly  in  the  vessels  of  the  ali- 
mentary canal  and  ulcerative  lesions  are  found  therein.  The  ova  appear 
in  the  feces.  Katsurada  has  studied  numerous  cases.  This  condition 
is  known  in  Japan  as  the  "Katayama  disease,"  from  the  name  of  a  town 
in  which  it  is  quite  prevalent. 

Catto  described  certain  bodies  he  found  in  a  Chinaman  in  1904,  and 
the  new  fluke  is  sometimes  called  by  his  name. 

Paul  G.  WooUey^  has  reported  a  case  occurring  in  the  Philippines,  and 
has  given  an  excellent  description  of  the  disease. 

The  worms  are  characterized  by  the  absence  of  ciliated  warts  on  the 
integument,  which  are  a  feature  of  the  Schistosoma  hcematohium.  The  worm 
averages  10.43  "im.  long.  The  eggs  are  smaller,  brown  in  color,  have 
blunter  ends,  and  no  spine. 

Katsurada  gives  the  most  definite  reports  of  the  disease  "Katayama," 
according  to  Woolley: 

"Defective  physical  developments  is  the  rule  in  the  affected  children. 
Diarrhea  is  usually  the  first  symptom  to  be  noted,  while  anemia  and 
ascites  generally  follow  later;  the  most  striking  feature  is  the  shape  as- 
•  Philippine  Jour,  of  Sci.,  Jan.,  1906,  vol.  i,  No.  i. 


934 


DISEASES   OF   THE    STOMACH   AND  INTESTINES 


sumed  by  the  trunk.  The  hypogastric  region  seems  to  shrink,  while  the 
epigastric  enlarges,  a  transverse  furrow  forming  directly  above  the  um- 
bilicus, so  that  the  general  appearance  of  the  abdominal  region  is  that  of 
an  inverted  gourd.  Dilatation  of  the  epigastric  region  and  of  the  lower 
part  of  the  thorax  were  noted  even  in  patients  whose  liver  and  spleen  were 
not  much  enlarged.  The  commonest  symptoms  are  an  initial  increase  in 
the  size  of  the  Uver,  followed  by  a  decrease,  a  secondary  enlargement  of 
the  spleen,  a  mucosanguineous  diarrhea,  severe  attacks  of  ascites,  and 
progressive  anemia."  Katsurada  found  the  ova  of  the  parasite  under 
discussion  and  also  those  of  Trichocephalus  dispar,  Uncinaria,  and  Ascaris 
lumbricoides  in  the  stools  of  his  patients. 

The  rectum  and  appendix  were  the  parts  chiefly  affected,  but  the  ova 
were  found  in  the  subperitoneal  layer,  the  submucosa,  and  mucosa,  es- 


Fig.  386. — Schistosoma  Japanicum.  Ova  in  mucosa  and  submucosa  of  large 
intestine.  Shows  atrophic  and  infiltrated  condition  of  mucosa.  Hematoxylin 
(Woolley). 

pecially  in  necrotic  areas,  from  the  cecum  to  the  anus.  Adult  trematodes 
were  found  in  the  blood-vessels. 

In  Woolley 's  case  there  were  also  amebae  and  the  ova  of  the  uncinaria; 
but  in  the  fibroid  tissue  of  the  submucosa  of  the  large  intestine  there 
were  many  ova  of  the  Schistosoma  Japanicum  surrounded  by  round-cell 
infiltration  (Fig.  386).  A  type  of  cirrhosis  was  produced  in  the  liver. 
Splenomegaly,  ascites,  dysentery  (specific),  and  possibly  Jacksonian 
epilepsy  may  be  produced  by  these  trematodes. 

The  disease  is  probably  water-borne,  originating  in  rice-fields  or 
irrigated  gardens,  from  human  fertilizer.  Infection  may  occur  through 
the  skin  or  by  the  gastro-intestinal  canal. 

Treatment. — The  extract  of  the  male  fern  is  recommended  for  dis- 

tomiasis  and  the  treatment  as  of  tapeworm.     Nothing  has  been  found 

for  the  treatment  of  the  parasite  in  the  blood.     The  author  would  suggest 

the  trial  of  urotropin,^  10  grains  (10.6),  and  sodium  benzoate,  10  grains 

^  Hexamethylenamin  in  same  dosage  may  be  substituted. 


INTESTINAL   PARASITES  935 

(0.6),  four  to  six  times  a  day.  The  latter  lessens  the  irritation  of  the 
urotropin  (hexamethylenamin). 

The  inflammation  of  the  bladder,  colon,  and  rectum  should  be  treated 
as  indicated  by  irrigation,  etc.  Solutions,  as  described  under  Proctitis 
and  Colitis,  can  be  employed  for  the  latter  complications. 

Nematodes  (Round  Worms). — Round  worms  have  a  slender,  cylindric, 
at  times  a  filiform  body,  with  neither  segments  nor  appendages.  The 
integument  is  thick  and  elastic.  The  mouth  is  at  one  extremity  and 
furnished  with  either  soft  or  horn-like  lips.  The  alimentary  canal  extends 
through  the  entire  body  and  terminates  in  an  opening  on  the  ventral  side 
near  the  posterior  extremity.  The  sexual  organs  and  their  orifices  are  on 
the  ventral  surface.  The  female  aperture  is  at  the  middle  of  the  body, 
while  in  the  male  the  sexual  orifice  is  near  the  anus.  The  males  are  usually 
smaller  than  the  females. 

Ascaris  Lumbricoides  (Round  or  Spool  Worm). — This  is  one  of  the 
common  parasites  observed  in  man.  It  is  cylindric  in  shape,  pointed  at 
both  ends,  and  of  a  yellowish-brown  or  slightly  reddish  color.  It  varies 
from  4  to  12  inches  (10-30  cm.)  in  length,  the  female  being  as  large  as  12 
inches  (30  cm.),  while  the  male  is  only  one-half  or  two-thirds  the  length, 
8  inches  (20  cm.),  and  frequently  much  smaller. 

The  posterior  extremity  of  the  male  is  bent  in  the  shape  of  a  hook 
and  furnished  with  two  spicules  or  chitinous  processes  (Fig.  387).  The 
mouth  has  three  muscular  lips  provided  with  very  fine  teeth. 

The  worm  is  transversely  striated  and  has  four  longitudinal  bands. 

The  sexual  opening  of  the  female  is  anterior  to  the  middle  of  the  body. 
The  eggs  when  ripe  have  a  double  shell,  and  around  this  is  an  albuminous 
envelope,  irregular  in  shape,  studded  with  excrescences  (Fig.  388).  The 
long  diameter  of  the  ovum  is  about  0.075  mm.  and  0.058  mm.  in  width. 
Atypic  (unfertilized)  eggs  have  been  described  by  O.  T.  Logan^  of  China. 
When  taken  from  the  uterus  it  has  not  the  typic  thick  shell  but  is  granular, 
elliptic,  and  enclosed  in  a  delicate  membrane  (Fig.  389). 

In  the  feces,  the  yolk  is  not  finely  granular,  but  coarsely  globular; 
the  albuminous  coat  is  less  voluminous  and  projects  from  the  shell  like 
blunt  saw  teeth.  The  unfertilized  egg^  is  longer  and  narrower  than  the 
fertilized  egg  and  markedly  elliptic,  with  a  tendency  to  flatten  at  one  or 
both  ends.     It  is  occasionally  oval,  but  never  round. 

An  irritating,  odoriferous  substance  is  formed  by  the  round  worm. 
Huber^  states  that  it  may  occasion  urticaria  in  those  predisposed  to  this 
symptom.  Peiper  suggests  that  the  nervous  symptoms,  sometimes 
resembling  meningitis,  may  be  due  to  this  poison;  and  Chaufard  and 
Marie  report  fever,  intestinal  symptoms,  diarrhea  of  intermittent  character 
and  foul  breath,  so-called  typholumbricosis,  in  connection  with  these 
worms.     The  fever  may  continue  for  a  month  or  more. 

The  parasitic  life  history  is  direct,  by  ingestion  of  the  ova,  with  no 
intermediate  host.  The  parasite  occupies  the  upper  part  of  the  small 
intestine.  Usually  not  more  than  one  or  two  are  present,  but  they  may 
occur  in  enormous  numbers. 

^  N.  Y.  Med.  Jour.,  Dec.  21,  1907. 

^Ibid.,  Aug.  19,  1905  (Wellman) ;  Reference  Handbook  Med.  Sci.,  p.  502. 

'Twentieth  Century  Practice  of  Medicine,  vol.  viii,  p.  583. 


936 


DISEASES    OF   THE    STOMACH    AND    INTESTINES 


Infection  usually  takes  place  by  eggs  in  the  soil  near  dwellings,  in  the 
drinking-water,  and  especially  in  raw  foods,  such  as  salads  and  fruits. 
These  worms  occur  more  frequently  in  children  from  three  to  twelve  years 
of  age  and  in  the  poorer  class.  They  are  not  so  frequent  in  adults.  Fe- 
males seem  more  frequently  infected. 

Migration. — The  worms  may  crawl  into  the  stomach,  whence  they 
may  be  ejected  by  vomiting;  or  they  may  pass  through  the  esophagus  and 
enter  the  pharynx,  whence  they  may  be  withdrawn.  The  worm  has 
entered  the  larynx  and  has  produced  fatal  asphyxia,  or  into  the  trachea 
and  lungs  and  caused  gangrene.  They  have  passed  through  the  Eu- 
stachian tube  and  appeared  at  the  external  meatus.  They  have  been  found 
in  the  bile-ducts,  pancreatic  duct,  the  gall-bladder,  and  even  in  the  liver, 
where  they  produced  fatal  abscess.     They  have  entered  hernial  sacs, 


I'ig.  388. — Eggs  of  Ascaris  lumbricoides, 
double  shell;  albuminous  envelope,  magni- 
fied (Mosler  and  Peiper). 


Fig.  387.— Ascaris  lumbricoides:  a,  Body, 
b,  head;  c,  eggs  (after  v.  Jacksch). 


Fig.  389. — Unfertilized     egg    of    Ascaris 
lumbricoides;  X  500  (Logan). 


perforated  intestinal  ulcer,  and  some  claim  even  the  healthy  bowel  wall 
has  been  perforated  by  them.  Appendicitis  has  been  attributed  to  the 
ascaris;  and  obstruction  of  the  bowel  has  been  produced  by  a  large  mass 
of  ascarides. 

Symptoms. — ^They  may  produce  no  symptoms.  In  children,  irri- 
tability, restlessness,  picking  at  the  nose,  grinding  the  teeth,  twitchings 
or  convulsions,  have  been  attributed  to  them.  Anorexia,  nausea,  irregular 
bowel  action,  meteorism,  irregular  pulse,  and  black  rings  around  the 
eyes  may  also  occur.  In  rare  instances  progressive  anemia  has  been  ob- 
served. Itching  of  the  nose  may  be  present.  The  worms  probably 
produce  local  hyperemia  of  the  intestinal  walls. 

Hemorrhage  from  the  bowel,  simulating  an  occult  ulcer,  may  be  pro- 
duced by  a  lumbricoid  worm.     The  following  interesting  case  is  reported 


INTESTINAL   PARASITES  937 

to  me  by  H.  D.  Meeker.  The  possibility  of  hemorrhage  from  an  occult 
duodenal  ulcer  was  suggested.  The  author  was  present  during  part  of 
the  operation  and  examined  the  worm. 

Mrs.  L.  P.  consulted  me  in  April,  191 1,  for  irregular  bleeding  from  the  bowel.  She 
gave  the  following  history- :  Age  twenty-five  years,  housewife,  married  four  and  a  half 
years,  no  children,  family  history  negative.  She  could  recall  no  serious  illness  of  any 
sort.  Four  years  ago  a  slight  bleeding  from  the  bowel  was  noticed,  a  few  weeks  later  a 
second  hemorrhage  occurred,  and  the  patient  purchased  medicine  for  piles.  There 
was  no  pain  associated  with  the  attacks.  The  hemorrhages  continued  at  intervals  of 
one  to  six  weeks,  the  amount  of  blood  varying  from  a  mere  trace  to  nearly  a  quart  in 
twenty-four  hours.  The  blood  was  always  dark  in  color  and  usually  clotted.  The  pa- 
tient, after  several  weeks  of  treatment  by  her  family  physician,  was  sent  to  a  Boston 
hospital  where  she  remained  a  month  without  apparent  benefit.  She  then  went  to 
Baltimore  to  live,  where  she  received  both  private  and  hospital  treatment.  Not 
finding  relief  at  the  hands  of  the  various  internists,  she  sought  help  from  Christian 
Science  with  equally  disappointing  results.  The  day  prior  to  admission  to  the 
Red  Cross  Hospital  the  patient  had  passed  approximately  2b  ounces  of  blood-clots. 
She  was  anemic,  her  blood  count  showing 3, 500,000  red  blood-corpuscles.  Hemoglobin, 
70  per  cent.  Aside  from  an  indefinite  tenderness  of  the  abdomen,  she  gave  no  sub- 
jective symptoms,  appetite  and  digestion  had  alwajs  been  good,  bowels  inclined  to 
be  loose.  Stomach  washings  and  examination  of  the  stools  were  negative  so  far  as 
throwing  light  on  the  cause  of  the  condition  was  concerned.  The  sigmoidoscope 
revealed  a  healthy  intestinal  mucosa.  In  view  of  the  negative,  subjective  and  objective 
symptoms,  and  j'et  persistent  bleeding,  exploratory  laparotomy  was  proposed  and 
welcomed  by  the  patient.  A  small  right  Battle  incision  was  made  in  the  mid-abdomen, 
permitting  exploration  in  both  directions.  All  the  abdominal  viscera  were  examined 
and  found  normal  with  the  exception  of  the  ileum  as  hereafter  described.  The  small 
gut  was  examined  inch  bj'  inch  and  appeared  normal  up  to  a  point  about  5  feet  from  the 
ileocecal  valve  where  an  area  about  5  feet  long  was  found  deeply  injected.  At  the 
mesenteric  border  the  condition  of  the  tissue  sugggested  a  healed  ulcer.  Another  in- 
jected area  was  found  2  feet  nearer  the  valve  about  6  inches  in  length.  Within  this  area 
doubled  on  itself,  was  felt  a  moving  worm.  The  intestine  was  opened  after  observing 
the  usual  protective  technic,  and  the  worm  extracted.  A  small  bleeding  was  observed 
at  the  mesenteric  attachment  of  the  gut,  this  was  excised,  and  the  opening  into  the 
ileum  closed.  No  other  pathological  condition  of  the  abdominal  contents  was  observed. 
The  worm  was  of  the  Ascaris  lumbricoid  family,  a  male  measuring  1 1 14  inches.  The 
patient  made  a  prompt  recovery.  She  has  been  seen  at  intervals  of  two  weeks  and  up 
to  the  present  writing  has  had  no  further  bleeding.  Her  hemoglobin  has  increased  10 
per  cent.  A  second  blood  count  has  not  been  taken.  Eosinophilia  was  never  present  at 
any  time  nor  were  any  ova  or  other  intestinal  parasites  discovered.  The  various  hemor- 
rhages which  occurred  for  a  period  of  four  years  were  evidently  due  to  perforations  of  the 
gut  vessels  by  a  single  male  worm. 

Chronic  intestinal  obstruction,  gradually  becoming  acute,  may  be 
caused  by  a  large  mass  of  the  ascaris  lumbricoides.  Such  a  case  has 
been  described  under  Acute  Intestinal  Obstruction. 

Allen^  of  Hannadam,  Persia,  describes  an  interesting  case  of  intra- 
abdominal abscess  apparently  due  to  the  ascaris.  Enterospasm  from 
ascarides  has  been  reported  by  Schaal  and  Swain.  2  In  case  of  the  former 
laparotomy  was  performed  for  suspected  perforation  of  gastric  ulcer. 

Diagnosis. — This  is  made  by  the  detection  of  the  worm  or  of  its  ova  in 
the  stools. 

Treatment. — The  stools  should  be  disinfected  by  carbolic  (5  per  cent.) 

^  Journal  A.  M.  A..  June  21,  1913. 

*  Miinchener  medizinische  Wochenschrift,  Sept.  26,  191 2,  lix,  No.  48. 


938 


DISEASES    OF   THE    STOMACH  AND   INTESTINES 


or  bichlorid  (i  :  looo)  solution  to  destroy  the  ova.  The  hands  should 
be  disinfected  and  all  food  protected  against  infection. 

It  is  preferable  to  administer  a  simple  saline  cathartic  for  a  couple 
of  days  and  keep  the  patient  on  a  light  diet  before  administering  the 
anthelmintic. 

Santonin  is  the  best  remedy.  It  can  be  given  mixed  with  sugar  in 
doses  of  3^  to  3^  grain  (0.022-0.032)  for  a  child,  and  2  to  3  grains  (0.13- 
0.194)  for  an  adult,  followed  by  calomel  or  a  saline  purge. 

It  can  be  administered  in  divided  doses;  thus,  santonin,  i  grain  (0.06), 
three  or  four  times  a  day,  followed  by  a  purge;  or  santonin,  33.^  grains 
(0.2),  with  castor  oil,  2  ounces  (60.0);  give  i  teaspoonful  for  a  small  child; 


Fig.  390. — Oxyuris  vermicularis:  Female,  enlarged  (Hosier  and  Peiper). 

I  dessertspoonful  for  a  larger  child;  i  tablespoonful  for  an  adult,  two  or 
three  times  daily  (Einhorn). 

Santonin,  }4  grain  (0.022);  hydrargyrum  choridum  mite,  i  to  2  grains 
(0.065-0.13).  Give  one  powder  t.i.d.  Yellow  vision  (xanthopsia) 
occasionally  follows  the  use  of  santonin. 

Chenopodium  (powdered  seeds),  in  doses  of  15  to  30  grains  (1.0-2.0), 
or  oleum  chenopodii,  2  to  10  minims  (o.ii8r-o.592),  followed  by  a  cathartic, 
have  been  employed. 

Thymol,  7 H  to  30  grains  (0.5-2.0),  given  in  capsules  in  divided  doses 
and  followed  by  a  saline  cathartic,  has  been  recommended. 


Fig.  391. — Oxyuris  vermicularis,  natural  size:  i,  Female;  2,  males;  3,  ovum,  magnified 

(Vierordt). 


Enteroclysis  with  water,  to  which  a  few  drops  of  benzine  are  added, 
has  been  suggested;  but  I  scarcely  see  the  benefit,  as  the  habitat  of  the 
worms  is  in  the  small  intestine. 

Ascaris  Mystax. — This  is  a  round  worm  resembling  the  ascaris  lum- 
bricoides,  but  smaller  and  thinner.  It  is  found  chiefly  in  cats  and  rarely 
in  man.     No  special  symptoms  result. 

Ox3mris  Venniciil^s  (Thread-worm;  Pin-worm;  Seat-worm;  Awl- 
tail;  Maggot-worm). — This  parasite  occupies  the  rectum  and  colon.  It 
is  white  and  filiform. 

The  male  measures  about  4  mm.  (}4  inch)  in  length  and  the  female 
about  10  mm.  (%  inch)  (Figs.  390  and  391).     It  has  three  small  nob- 


INTESTINAL   PARASITES 


939 


like  lips.  The  female  has  two  uteri,  passing  backward  and  forward  from 
the  end  of  the  vagina.  The  opening  of  the  latter  is  situated  above  the 
middle  of  the  body.  The  eggs  are  0.05  mm.  long  and  about  0.02  mm. 
wide,  with  granular  contents  and  white  shell  (Figs.  391  and  392). 

Huber  and  others  claim  that  they  are  generally  deposited  outside  the 
body,  so  that  feces  rarely  contain  them;  while  Osier  holds  that  they  are 
usually  found  in  the  feces  in  large  numbers.  These  worms  occur  at  any 
age,  though  most  commonly  in  children.  The  worms  are  found  in  the 
feces,  at  the  anus,  or  in  the  vagina. 

Infection  takes  place  through  drinking-water  or  through  salads, 
radishes,  fruits,  etc.,  the  ova  being  dried  upon  them,  or  through  the  un- 
washed hands  of  the  host. 

The  eggs  of  the  oxyuris  reach  the  stomach,  when  the  shell  opens  and 
the  embryo  migrates  into  the  small  intestine.  After  fructification  the 
females  pass  along  the  canal  to  the  cecum,  where  they  remain  until  the 
eggs  are  ripe,  and  then  pass  on  downward,  chiefly  to  the  sigmoid  and 


Fig.  392.— Segmentation  and  development  of  embryo  of  Oxyxiris  vermicularis  (Heller). 

rectum.  The  oxyuris  may  traverse  the  intestinal  wall  and  have  been 
found  in  the  peritoneal  cavity,  where  they  may  form  verminous  tubercles 
in  Douglas'  fossa  or  perirectal  abscesses. 

Symptoms. — The  oxyuris  produce  great  irritation  and  itching  around 
the  anus,  particularly  at  night.  The  pruritis  ani  is  pronounced.  The 
patient  becomes  nervous  and  irritable,  sleep  is  disturbed.  There  may 
be  anorexia,  nausea,  dizziness,  palpitation,  pollutions  in  the  male,  oc- 
casionally diarrhea,  and  at  times  anemia.  Sometimes  the  parasites  enter 
the  vagina  and  cause  irritation,  or  nymphomania. 

Diagnosis. — The  worms  are  easily  detected  in  the  feces  and  are  readily 
diagnosed  by  their  appearance  and  location  through  inspection  of  the 
anus. 

Treatmettt. — Cleanliness  of  the  hands  of  the  infected  person  and  dis- 
infection of  stool,  clothes,  and  bedclothes  are  important.  Sleeping  with 
an  infected  case  should  be  forbidden. 

Raw  fruits  should  be  cleaned  and  peeled,  salads,  etc.,  thoroughly 
washed.     One  should  not  eat  out  of  the  same  vessels  as  the  patient. 


940  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Santonin,  administered  by  the  same  method  as  for  ascaris,  is  an  ex- 
cellent remedy.  Local  treatment  by  enemata  of  water,  i  quart  (liter) 
containing  5  to  10  minims  (0.296-0.592)  of  benzine,  or  vinegar  ij-^  to  2 
ounces  (45.0-60.0),  or  thymol  (i :  2500)  by  enema,  or  fluidextractof  quassia, 
10  to  30  minims  (0.292-1.704)  to  the  quart;  or  soak  a  quassia  cup  in 
water  for  half  an  hour  and  inject  quassia  water,  i  pint  (500  c.c). 

An  enema  of  spirits  (oil)  of  turpentine,  i  dram  (4.0)  to  i  pint  (500 
c.c.)  of  water,  is  of  value. 

These  injections  should  be  given  with  hips  elevated  and  retained  for  a 
short  period.  Cold  injections  of  strong  salt  water  are  of  service  in  children. 
Carbolic  acid  I  believe  unsafe.     Injections  of  limewater  are  of  use. 

Blackwash — calomel,  i  dram  (4.0);  lime-water,  i  pint  (500  c.c.) — 
locally,  externally;  lead-and-opium  lotion,  unguentum  belladonna,  vase- 
lin,  or 

I^.  Unguent,    belladonnae 5ij  (8.0); 

Tr.  aconite  radix 5ss  (2.0); 

Zinc  oxid gr.  xv  (i.o); 

Unguent,  aq.  rosae q.s.  5 j  (30.0). — M. 

Sig. — Ft.  ung.     External  use  to  anus. 

Cocain,  J^  grain  (0.32),  can  be  added  to  this.  These  preparations 
lessen  itching. 

The  saUne  enemata,  given  frequently,  are  of  use. 

Ankylostoma  (Anchylostoma)  Duodenale;  Uncinariasis;  Hook-worm 
Disease;  Miner's  Anemia;  Egyptian  Chlorosis;  Dochmius  Duodenalis 
or  Strongylus  Duodenalis. — In  1843  Dubini  first  described  this  parasite 
in  man.  Griesinger,  in  1854,  demonstrated  it  as  the  cause  of  Egyptian 
chlorosis.  Subsequently  it  was  described  in  the  tunnel  workers  of  St. 
Gothard,  and  it  is  now  recognized  as  an  important  cause  of  tropical  anemia 
and  of  the  anemia  of  miners,  brick  workers,  and  tunnel  workers. 

It  is  interesting  to  note  that  as  far  back  as  1886,  the  late  Prof essor 
Joseph  Leidy  reports  in  an  article  entitled  "Remarks  on  Parasites  and 
Scorpions,"  May  5,  1886,  his  discovery  of  true  ankylostoma  duodenale 
infesting  a  cat.  He  refers  to  the  probability  that  some  of  the  cases  of 
supposed  pernicious  anemia  found  in  America  are  due  to  this  parasite. 
Leidy's  researches  are  to  be  found  at  the  Smithsonian  Institution. 

Incidence. — This  parasite  is  widely  spread  in  tropical  and  subtropical 
countries,  and  is  one  of  the  most  fatal  of  parasitic  diseases.  In  Porto 
Rico,  in  1903,  5736  deaths  out  of  a  total  of  23,433  were  from  anemia  due 
to  uncinariasis,  as  shown  by  the  Anemia  Commission  in  the  report  issued 
by  Ashford,  King  and  Igaravidez.  In  Porto  Rico,  Colombia,  Dutch 
Guiana  and  Ceylon  about  90  per  cent,  of  the  population  were  in  former 
years  infected  by  this  parasite.  A  summary  of  ten  years'  campaign 
against  hookworm  disease  is  reported  by  these  authors.^  Stiles  has  demon- 
strated that  the  disease  is  endemic  in  many  places,  and  is  the  cause  of  the 
common  anemia  in  the  Southern  States. 

Harlow  Brooks^  reports  a  case  of  hookworm  infection  endemic  in 
New  York.     This  patient  had  been  working  on  the  reservoir  at  Brewster, 

'  Jour.  Amer.  Med.  Assoc,  May  28,  1910. 
2  Med.  Rec,  Jan.  29,    1910. 


INTESTINAL    PARASITES  94 1 

N.  Y.  He  was  of  Irish-American  extraction.  A  number  of  his  asso- 
ciates were  ItaUans  recently  arrived  in  this  country.  The  European 
form  of  the  worm  was  found  in  this  patient's  stools.  Stiles^  has  ex- 
amined the  pupils  of  eight  schools,  1306  children  inspected,  and  classified 
55.9  per  cent,  as  "suspects"  as  regards  hookworm  disease  in  Southern 
Florida.  He  believes  the  condition  lamentably  common  in  the  South. 
Wells^  investigating  uncinariasis  in  the  State  of  Georgia,  finds,  exclusive 
of  the  large  towns,  about  24  per  cent,  of  the  total  white  population  have 
uncinariasis.  Infection  seemed  to  be  confined  chiefly  to  those  between  five 
and  twenty-seven  years  of  age,  and  the  parasites  may  live  in  the  intestines 
from  two  to  twelve  years. 

Bass^  has  reported  a  large  number  of  cases  in  the  country  population 
of  Mississippi.  Uncinariasis  has  been  found  among  the  miners  in  Pennsyl- 
vania and  has  been  reported  in  Texas,  Missouri,  Arkansas  and  Oklahoma. 

Gunn"*  reported  in  1905  about  60  cases  of  imported  hookworm  disease 
in  the  state  of  California.  Sprague  and  Endicott  have  reported  the  occur- 
rence of  this  disease  in  Jackson,  Amador  Co.,  in  the  same  state,  and 
Gunn^  more  recently  reports  a  large  series  of  cases  of  hookworm  disease 
in  the  mines  of  California,  and  on  investigation  finds  the  disease  is  endemic 
in  certain  mines,  hookworm  embryos  being  demonstrated  in  the  earth 
removed  from  these  mines.  The  condition  is  also  found  in  Nevada  and 
probably  exists  in  many  other  mines  in  the  United  States.  Unsanitary 
conditions  in  the  mines  are  undoubtedly  responsible.  In  many  of  them 
there  are  no  privy  facilities  underground.  The  severest  infection  occurs 
from  the  light  sandy  soil  of  the  coastal  plains.  It  occurs  frequently  in  the 
agricultural  districts.  From  1910  to  1913  examination  of  415,000  school 
children  in  413  counties  of  11  Southern  States  revealed  an  infection  of 
43  per  cent.  Of  over  700,000  persons  of  all  ages,  35  per  cent,  were  infected. 
Protection  against  this  infection  is,  therefore,  of  interest  on  the  economic 
as  well  as  on  the  humanitarian  side.  Ford^  reports  a  case  of  hookworm 
disease  in  Kansas. 

It  is  not  uncommon  in  the  Philippines.  Chamberlain^  reports  a  sta- 
tistical study  of  hookworm  among  the  whites  in  the  Philippines,  and 
Castellani  and  Chalmers  in  the  July  issue  of  the  same  Journal,  intestinal 
flagellates  occurring  with  hookworm.  The  disease  is  prevalent  among  the 
miners  of  Germany  and  Austro-Hungary  and  also  in  Westphalia.  The 
anemia  of  the  Cornish  miners  has  been  shown  to  be  due  to  hookworm. 
In  Egypt  the  disease  is  very  prevalent. 

Parasite. — The  worm  is  a  strongyle,  closely  allied  to  the  sclerostoma, 
which  causes  verminous  aneurysms  and  colic  in  the  horse,  and  to  the 
gapeworm  of  fowls.  There  are  two  forms — the  Anchylostoma  duodenale 
and  the  Uncinaria  americana  or  Necator  americanus — described  by 
Stiles.  They  have  the  same  general  characteristics,  there  being  certain 
differences  in  the  arrangement  of  the  teeth,  etc. 

'  Public  Health  Reports,  March  25,  19 10. 

^  Jour.  Amer.  Med.  Assoc.,  June  4,  19 10. 

^  Ibid.,  July  21,  1906. 

*  California  State  Jour.  Med.,  April  and  Aug.,  1905. 

6  Jour.  Amer.  Med.  Assoc,  Jan.  28,  1910. 

^  Jour.  Amer.  Med.  Assoc,  May  28,  1910. 

'  Philippine  Jour,  of  Sci.,  Aug.,  1910. 


942 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


The  worm  is  cylindric  in  shape,  about  0.5  to  i  mm.  thick.  The 
males  are  from  7  to  11  mm.  in  length,  the  females  10  to  18  mm.  The 
American  worm  is  the  longer.  The  worm  is  yellowish  or  grayish-white 
in  color,  with  translucent  edges.     The  head  is  curved  toward  the  dorsal 


Fig.  393. — Ankylostomum  duodenale:  a,  Male  (natural  size);  b,  female  (natural  size); 
c,  male  (enlarged);  d,  female  (enlarged);  e,  head;/,  eggs  (after  v.  Jaksch). 

surface  and  the  mouth  is  provided  with  a  heavy  armature  of  hook-like 
teeth,  with  which  they  pierce  the  mucosa.  There  is  a  strong  muscular 
esophagus.  The  male  has  a  prominent  caudal  expansion  or  bursa 
(Fig-  393)- 


Fig.  394. — Posterior  extremity  of  female  Uncinaria  Americana,  viewed  ventro- 
lateraUy,  showing  anal  opening  expanded:  a,  a,  Anal  papillae,  showing  small  chitinous 
tips  (A.  J.  Smith). 

In  the  female  the  caudal  end  is  pointed  and  armed  with  an  awl-like 
prong  (Fig.  394).  The  female  worms  number  about  four  to  one.  The 
eggs  are  oval,  64  to  76  n  long  by  36  /x  wide  (Fig.  395)  in  the  American 
form.  They  are  laid  in  segmentation.  The  development  is  direct, 
without  an  intermediate  host.     The  European  eggs  are  smaller.     Some- 


INTESTINAL   PARASITES 


943 


times  as  many  as  2,000,000  eggs  are  found  in  one  stool.  They  do  not 
hatch  in  the  intestines.  Sometimes  they  are  not  readily  found  in  the 
microscopic  field  and  centrifuging  the  specimen  may  be  necessary. 

Bass  affirms  that  more  than  7  per  cent,  of  females  out  of  247  whom  he 
dissected  failed  to  produce  ova.  He  maintains  that  during  the  latter 
third  of  their  existence,  they  cease  to  lay  eggs.  If  this  observation  is 
substantiated,  in  some  cases  individuals  may  be  harboring  the  worm, 
though  no  ova  can  be  found  in  their  stools. 

The  embryo  lives  in  the  water  or  moist  ground  and  passes  through 
the  rhabditiform  stage.  Larvae  may  live  for  months  in  the  mud  and  water 
of  the  mines.  They  may  be  taken  into  the  body  by  drinking  water,  with 
the  dirt  from  the  hands  of  the  miners  and 
tunnel  workers,  or  in  the  soil  eaten  by  the 
earth  feeders,  the  geophagi.  They  may  be 
carried  in  the  dust  and  contaminate  green 
vegetables  and  fruit. 

Uncinarial  Dermatitis. — Ashford  and 
King^  refer  to  the  fact  that  in  Porto  Rico 
infections  through  the  mouth  are  rare,  and 
that  fully  96  per  cent,  of  the  patients  have 
suffered  from  ground-itch  ("Mazamorra"), 
or  dew-itch,  diie  to  invasion  of  the  skin^  by 
these  larva.  The  well  shod  were  never  affected. 
Various  stages  of  dermatitis  occur,  and  even 
obstinate  ulcers  of  the  leg,  in  the  lower  third 
especially.  These  were  called  " tropical"  or 
"  syphilitic  "  by  the  ignorant.  Next  in  fre- 
quency to  infection  through  the  skin  of  the 
feet  are  the  hands  and  arms  as  the  route  of 
entrance.  Loos  demonstrated  that  embryo 
worms  enter  the  skin,  the  lymph-channels, 
and  then  the  veins,  and  are  carried  by  the 
veins  to  the  right  side  of  the  heart  and  lungs, 
and  then  pass  up  through  the  trachea  into 
the  pharynx  and  are  swallowed.  Ashford 
further  believes  that  skin  infections  can  take  place  without  manifest 
dermatitis,  from  experiments  on  animals.  Skin  infection  is  probably  very 
frequent.  Infection  is  more  common  in  summer  than  winter,  in  part 
probably  due  to  the  fact  that  greater  protection  is  afforded  the  lower 
limbs  during  the  cold  or  rainy  season. 

Immunity. — Some  whites,  and  especially  the  negro  race  and  Asiatics, 
enjoy  considerable  immunity  to  this  disease.  One  may  find  a  large 
number  of  ova  in  the  stools,  and  yet  there  may  be  few  or  no  symptoms. 
Usually  the  greater  the  infection,  the  more  acute  the  onset  and  course  of 
the  disease.  The  adult  worm  lives  in  the  small  intestine;  more  are  found 
in  the  jejunum;  many  in  the  duodenum;  and  rarely  in  the  ileum  or  colon. 

^  Uncinariasis,  Jour.  Amer.  Med.  Assoc,  Aug.  10,  1907. 

*  The  skin  eruption  known  as  "bunches,"  occurring  in  the  Cornish  miners  is  probably 
due  to  the  entrance  of  these  worms  (Haldane). 


Fig.  395. — Four  eggs  of  the 
New  World  hookworm  (Unci- 
naria  Americana),  in  the  one-, 
two-,  and  four-cell  stages.  The 
egg  showing  three  cells  is  a  lateral 
view  of  a  four-cell  stage.  These 
eggs  are  found  in  the  feces  of 
patients,  and  give  a  positive  di- 
agnosis of  infection.  Greatly 
enlarged  (after  Stiles). 


944  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Symptoms. — Chronic  Cases. — It  is  interesting  to  note  the  retarding 
of  mental  and  physical  development  of  children  infected  with  this  parasite. 
In  cases  reported  by  FerrelP  malaria  and  tuberculosis  have  been  diag- 
nosed, when  eventually  the  emaciation,  anemia  and  loss  of  strength  were 
found  to  be  due  to  hookworm  infection.  Many  of  the  infected  children 
have  a  prominent  abdomen  (pot  belly),  the  chest  is  flat  and  the  shoulder- 
blades  stand  out  prominently  suggesting  "angel  wings"  and  are  denomi- 
nated this  t)q)e  of  shoulder-blade;  even  in  the  less  severe  types  of  cases, 
these  patients  become  somewhat  weak  and  anemic,  unable  to  properly 
perform  the  physical  or  mental  labor  and  the  disease  thus  affects  their 
wage-earning  capacity,  so  that  from  an  economic  standpoint  as  well  such 
infections  are  a  serious  menace  to  the  prosperity  of  a  community.  In 
the  early  stage  of  more  acute  cases  there  may  be  gastro-intestinal  symp- 
toms, such  as  pains  in  the  epigastrium  (gastralgia),  tenderness  in  the  right 
hypochondrium,  nausea,  occasionally  vomiting,  constipation,  rarely 
diarrhea.  Pain  in  the  sternum  and  chest,  slight  breathlessness  on  exer- 
tion, and  palpitation.  A  temperature  of  37.5°  to  38.5°C.  (99.5°-io3.5°F.) 
is  not  uncommon.  The  patient  feels  unable  to  work;  gradually  anemia 
becomes  manifest,  the  fever  disappears,  hemoglobin  steadily  diminishes. 
Headache,  vertigo,  tinnitus  aurium,  hemic  murmurs,  weakening  of  the 
pulse,  and  dyspnea  follow.  The  pains  in  the  sternum  become  quite 
severe,  debility  and  mental  hebetude  increase;  patellar  reflexes  are 
diminished  or  even  lost.     Impotence  or  amenorrhea  may  be  present. 

In  this  advanced  condition  the  skin  is  of  a  dirty  muddy  hue,  at  times 
waxy  white.  In  the  Southern  States  it  is  known  as  the  "Florida  com- 
plexion." The  eyes  are  dull,  heavy,  lack  luster,  and  have  a  blank  stare. 
Children  are  interfered  with  in  their  growth  and  become  stunted  and  ill 
developed.  The  circulatory  system  becomes  more  profoundly  affected; 
the  heart,  at  first  slightly  h)rpertrophiedi  now  becomes  dilated  and  broken 
compensation  ensues.  There  are  edema  of  the  feet  and  legs,  puffiness, 
of  the  face  and  a  general  anasarca,  with  pericardial,  pleural,  and  peritoneal 
effusions.  The  patient  is  bedridden  and  gradually  passes  away  in  a 
semisomnolent  condition.  Acute  cardiac  dilatation,  cerebral  effusion, 
or  violent  diarrhea  may  be  terminal  events. 

Osier  holds  that  the  liver  and  spleen  become  enlarged,  but  this  does 
not  correspond  to  the  findings  of  Ashford  and  King.  The  hemoglobin 
may  fall  below  30  per  cent,  and  sometimes  even  to  8  per  cent.,  and  some 
of  these  latter  have  recovered  under  appropriate  treatment.  Eskridge" 
reports  a  case  of  Ainhum  complicating  uncinariasis. 

Morbid  Anatomy. — Autopsies  (Ashford  and  King). — Muscles  are  often 
brownish  gray,  friable  and  atrophied.  Skin  and  subcutaneous  tissue  pale 
and  sodden  with  fluid.  Serous  effusion  generally  present  in  the  pleurae 
and  pericardium,  sometimes  in  the  cerebral  ventricles.     Ascites  marked. 

Lungs. — Edema  and  passive  congestion. 

Liver. — Never  normal;  once  was  increased  in  size;  never  diminished; 
fatty  degeneration  often  present;  connective-tissue  increase  is  not  a 
feature. 

'  Journal  A.  M.  A.,  June  20,  1914. 
*  Med.  Rec,  Sept.  17,  1910. 


INTESTINAL  PARASITES  945 

Kidneys. — Chronic  parenchymatous  or  chronic  diffuse  nephritis.  As 
a  rule,  there  was  Uttle  connective-tissue  increase. 

Stomach. — Uncinariae  are  occasionally  found  in  the  stomach  and  even 
adherent  to  its  walls.     Chronic  gastritis  is  common. 

Intestines. — The  jejunum  contained  most  of  the  uncinariae,  some  unat- 
tached and  others  attached  to  the  mucosa.  The  balance  were  mostly  found 
in  the  first  part  of  the  duodenum,  a  few  in  the  ileum,  and  none  in  the  coon. 

The  intestinal  lesion  is  confined  to  the  mucosa,  there  being  a  tiny 
superficial  erosion  about  0.5  mm.  (3-50  inch)  in  diameter,  and  not  a  deep 
ulcer.  They  are  usually  not  red  and  are  difficult  to  find,  except  with  a 
hand  lens.  The  duodenum  and  especially  the  jejunum  are  the  seat  of  a 
chronic  intestinal  catarrh. 

The  dejecta  are  often  of  brownish  color.  Microscopically,  eggs  of  the 
parasites  and  at  times  Charcot-Leyden's  crystals  are  found  in  the  stools. 

Spleen. — This  is  frequently  found  reduced  in  size,  soft,  and  has  a 
wrinkled  capsule.     There  was  a  paucity  of  lymphoid  elements. 

Hemolymph  Glands. — In  the  region  of  the  abdominal  aorta,  especially 
near  the  bifurcation,  enlarged  glands  of  dull  reddish  hue  were  noted. 
There  was  no  surrounding  trace  of  inflammation.  Microscopic  examina- 
tion showed  they  were  hemolymph  glands  of  the  type  described  as 
splenolymph. 

Bone-marrow. — Changes  such  as  occur  in  pernicious  anemia;  also 
eosinophilous  cells. 

Anemia. — Blood. — The  findings  vary  from  a  diminution  of  hemoglobin 
and  red  cells  to  those  of  pernicious  anemia.  The  hemoglobin  is  usually 
relatively  lower  in  uncinariasis;  as  low  as  15  to  20  per  cent,  in  severe  cases 
is  not  uncommon,  8  per  cent,  having  been  registered. 

Polychromatophilia,  and  in  severe  cases  poikilocytosis,  with  macro- 
cytes,  and  microytes,  occur.  Normoblasts  and  megoblasts  were  not 
uncommon,  but  the  latter  were  in  the  minority.  Erythrocytes  averaged 
2,406,416  per  cubic  millimeter,  the  lowest  754,000;  average  hemoglobin 
slightly  over  40  per  cent. 

Osier  reports  marked  leukocytosis  in  his  cases.  Some  observers 
hold  that  leukocytosis  is  generally  due  to  complications;  while  Ashford 
and  King  find  no  constant  leukocytosis,  but  that  it  is  present  at  times  in 
acute  cases,  while  in  chronic  cases  there  is  apt  to  be  leukopenia.  There 
seemed  to  be  a  tendency  of  the  leukocytes  to  degenerate. 

Eosinophilia  is  of  importance.  Boycott  and  Haldane  hold  it  is  present 
in  94  per  cent,  of  cases,  and  at  times  it  is  quite  high.  Ashford  and  King 
call  especial  attention  to  the  fact  that  in  the  most  serious  cases  it  is  liable 
to  be  absent,  and  that  it  is  chiefly  of  prognostic  importance.  Very  chronic 
cases  of  severe  type,  poor  resisting  power,  and  lack  of  blood  regeneration, 
they  state,  rarely  show  eosinophilia,  or  only  to  a  slight  degree;  that  a  rise 
of  eosinophilia  is  of  good  prognostic  significance;  that  a  fall,  with  lack  of 
improvement  in  the  symptoms,  is  not  a  good  omen.  They  hold  that  good 
resistance  to  the  toxin  of  uncinariae  is  expressed  by  eosinophilia.  An  inter- 
esting case  of  fatal  acute  hook-worm  infection  with  purpura  is  reported 
by  Boiling  Lee  and  Harlow  Brooks.^     Eosinophilia  was  absent  probably 

'  Med.  Rec,  May  14,  1910. 
60 


946  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

by  reason  of  the  severe  character  of  the  infection  and  the  slight  body 
resistance  to  it. 

Diagnosis. — By  the  finding  of  the  eggs'and  parasites  in  the  stool.  It  is 
well  to  examine  the  stools  after  a  dose  of  thymol,  followed  by  a  saline 
cathartic.  Stiles  suggests  placing  a  small  bit  of  feces  on  a  white  blotting 
paper  when  a  microscopic  examination  cannot  be  made.  In  about  an 
hour  there  is  a  blood-red  or  reddish-brown  stain  suggestive  of  blood.  The 
worms  to  the  naked  eye  are  about  K  inch  long,  of  the  diameter  of  a  pin, 
with  one  end  sharply  recurved. 

Eosinophilia  is  suggestive.  The  microscopic  examination  of  the  stool 
will  settle  the  diagnosis.  It  is  interesting  to  note  that  other  intestinal 
parasites  or  their  ova  may  be  found  in  addition  to  the  hook-worm. 
Charcot-Leyden's  crystals  in  the  stool  are  also  suggestive. 

Prognosis. — This  is  good  if  the  condition  is  detected  early,  but  is  bad 
in  the  advanced  cases. 

Prophylaxis. — In  camps  or  mines,  proper  sanitary  regulations,  such 
as  the  correct  location  of  the  latrines,  etc.,  are  important.  In  regions 
where  this  infection  is  endemic,  new  miners  should  be  inspected,  and 
infected  cases  should  be  pronounced  free  from  the  disease  before  being 
allowed  to  resume  work.  The  feet  and  legs  should  be  protected  from  the 
soil  (should  not  be  bare)  and  the  hands  properly  scrubbed  before  eating. 
The  stools  of  infected  patients  should  be  disinfected  with  bichlorid  of 
mercury  (i :  1000)  or  carbolic  acid  (i  :  20)  solution. 

Raw  fruits  and  vegetables,  such  as  apples,  lettuce,  etc.,  should  be 
properly  cleaned,  and  should  preferably  be  avoided  if  there  are  many  cases 
of  ankylostomiasis. 

Treatment. — Filix  mas,  thymol,  and  betanaphtol  are  the  best  drugs. 
The  ethereal  extract  of  filix  mas,  same  dosage  as  for  tape-worms,  and 
then  the  solid  extract  were  tried  in  Porto  Rico,  but  they  seemed  to  be  of 
no  value.  Ashford  believes  that  possibly  the  preparation  deteriorates 
in  warm  climates.  In  the  early  stage  of  emigration  (uncinarial  dermatitis) 
the  author  suggests  the  possible  value  of  hexamethylenamin,  10  grains 
(0.6),  with  same  quantity  of  sodium  benzoate,  four  to  eight  times 
a  day. 

Thymol  proved  to  he  the  best  remedy. — The  day  previous  the  patient 
abstains  from  solid  food  and  at  night  is  given  25.0  grams  sodium  sulphate 
or  any  good  saline  cathartic;  the  next  morning,  if  free  bowel  action,  on 
an  average  about  30  grains  (2.0)- of  thymol  should  be  given  in  capsules, 
and  an  equal  dose  two  hours  later,  followed  in  a  couple  of  hours  by  another 
saline  cathartic. 

This  procedure  should  be  kept  up  once  a  week,  until  no  ova  are  found. 
Smaller,  occasionally  even  larger,  or  more  frequent  doses  may  be  required. 
It  is  generally  advised  that  oily  cathartics,  such  as  castor  oil  and  also 
alcohol  should  not  be  taken  directly  after  the  thymol.  Dizziness  or 
slight  collapse  may  follow  the  use  of  thymol.  Epigastric  pain,  nausea, 
vomiting,  tremors,  twitchings,  convulsions,  and  severe  collapse,  pulmonary 
congestion  and  fatty  degeneration  of  the  liver  result  from  thymol  poison- 
ing. Ashford  mentions  cases  who  have  taken  alcohol  for  these  conditions 
with  no  deleterious  effect. 


INTESTINAL   PARASITES  947 

Occasionally  thymol,  when  given  pulverized  in  capsules,  may  pass 
through  in  a  hard  stony  mass,  with  no  effect  on  the  parasites.  Lindeman^ 
recommends  triturating  the  thymol  crystals  with  equal  parts  of  milk- 
sugar  and  placing  the  mixture  in  cachets  which  are  softened  to  the  con- 
sistency of  a  raw  oyster  before  administering.  The  sugar  of  milk  is  dis- 
solved and  the  thymol  is  well  distributed  over  the  small  intestine.  An 
equal  quantity  of  powdered  sugar  or  creta  preparata  (precipitated  car- 
bonate of  chalk)  has  also  been  suggested  as  a  valuable  combination  with 
the  thymol.  Lindeman  believes  that  intestinal  catarrh,  rapid  peristalsis 
from  intestinal  erosions,  and  especially  dilatation  of  the  stomach,  with 
gastroptosis,  which  latter  condition  he  believes  frequent,  as  many  of  these 
patients  are  pot-bellied,  that  these  conditions  interfere  with  the  thymol 
coming  in  contact  with  the  parasite.  With  ectasy,  the  drug  would  lie 
too  long  in  the  stomach  and  part  be  absorbed.  It  is,  therefore,  recom- 
mended that  the  patient  lie  on  the  right  side  after  ingestion  of  the  thymol, 
so  the  stomach  can  readily  empty  itself.  The  following  dosage  is  outlined 
by  the  State  Board  of  Health  of  Florida. 

Under  5  years  of  age Up  to  8  grains. 

5  to  10  years  of  age 5  to  15  grains. 

10  to  15  years  of  age 15  to  30  grains. 

15  to  20  years  of  age. 30  to  45  grains. 

20  to  60  years  of  age 45  to  60  grains. 

Over  60  years  of  age 45  grains. 

One  should  also  consider  the  weight  of  the  child,  and  also  in  all  cases 
the  condition  of  the  heart  and  the  degree  of  debility. 

Bozzolo  administers  much  larger  adult  doses  of  thymol — 12  granis  in 
divided  doses — 2  grams  every  two  hours,  and  claims  the. best  results. 
He  administers  a  small  dose  of  strong  wine  or  alcohol  after  each  dose  of 
thymol  and  had  no  bad  results,  no  poisoning  and  no  other  phenomena 
beyond  giddiness  or  sleepiness,  with  dark  urine. 

Betanaphtol,  15  grains  (i.o),  and  two  hours  later  the  same  dosage, 
administered  like  thymol,  have  been  employed.  It  is  somewhat  irritating 
to  the  kidneys;  is  an  excellent  anthelmintic,  but  not  quite  as  safe  as 
thymol  nor  as  efficacious. 

Ashford  and  King  hold  that  hemoglobin  increased  more  rapidly  under 
the  use  of  iron,  but  that  the  return  to  normal  came  about  as  surely  with- 
out it,  after  the  use  of  thymol.  They  used  Blaud's  pills  in  obstinate 
cases.     Iron  and  arsenic  I  believe  valuable  accessories. 

I^.  Blaud's  pill  (iron)  (made  fresh) gr.  v.  (0,3) ; 

Sod.  arsen gr.  )^o  (0.0013). — M. 

One  pill. 
Sig. — One  t.i.d. 

Blaud's  iron  pill,  5  to  10  grains  (0.3-0,6),  or  iron  tropon  can  be  used, 
combined  with  Fowler's  solution  of  arsenic,  5  minims  (0.274),  t.i.d.;  or 
atoxyl,  ^i  grain  (0.02),  by  hypodermic  every  other  day. 

A  subsequent  high  enema  of  thymol,  i  quart  (liter),  1:2500,  might 
be  of  value  in  aiding  their  destruction  after  the  worms  have  passed  into 
the  large  intestine. 

*  Jour.  Amer.  Med.  Assoc.,  May  28, 1910. 


948 


DISEASES    OF    THE    STOMACH   AND   INTESTINES 


Autogenous  Vaccine  in  Ankylostomiasis. — Recent  observations  sug- 
gest that  the  hookworm  itself  is  not  always  exclusively  responsible  for 
the  symptoms  found  in  hookworm  infection,  since  different  types  of  fever 
and  intestinal  putrefactive  processes  are  very  marked  in  ankylostomiasis. 
R.  G.  Archibald  ascribes  the  evidences  of  toxemia,  unaccounted  for  by 
the  hookworm,  to  absorption  of  poisonous  products  of  certain  intestinal 
bacteria,  who  immediately  improved  after  the  administration  of  an 
autogenous  vaccine  prepared  from  a  coliform  organism  isolated  from  the 
stools.  He  suggests  use  of  autogenous  vaccines  prepared  from  the  stool 
previous  to  the  administration  of  the  anthelmintic  These  cases  seem 
to  the  author  an  associated  bacillus  coli  infection.  I  have  previously 
recommended  the  use  of  hexamethylenamin  for  ankylostomiasis. 

Strongyloides  Intestinalis. — Under  this 
name  we  now  include  the  small  nematode 
worms  found  in  the  feces  and  formerly  de- 
scribed as  Anguillata  stercoralis,  Anguillata  in- 
testinalis, and  Rhabdonema  intestinale.  The 
parasite  occurs  abundantly  in  the  stools  of  the 
endemic  diarrhea  of  hot  countries,  and  has  been 
described  by  the  French  in  the  diarrhea  of 
Cochin-China.  It  has  been  found  in  Manila 
by  Strong. 

W.  S.  Thayer  reported  three  cases  from 
Osier's  clinic.     It  has  occurred  in  Italy. 

Blumgart^  reports  their  larvae  in  a  case  and 
refers  to  reports  of  five  additional  cases,  and  to 
the  fact  that  Southern  physicians  refer  to  other 
cases,  so  that  the  disease  is  probably  more 
widespread  than  is  supposed.  The  worms  are 
said  to  occupy  all  parts  of  the  intestines,  and 
have  even  been  found  in  the  biliary  and  pan- 
creatic ducts. 

The  female  is  from  i  to  2.20  mm.  long  and 
0.04  to  0.03  mm.  wide  (Fig.  396).  The  mouth 
has  three  distinct  lips,  continuous  with  a  triangu- 
lar esophagus,  which  after  narrowing  dilates 
again  into  a  second  ovoid  enlargement,  which  is  followed  by  intestines. 
The  esophagus  is  one-fourth  the  length  of  the  body.  It  has  a  double 
uterus,  each  horn  of  which  contains  from  three  to  six  segmentary  ova 
which  escape  through  the  vulva.  The  intestinal  tract  is  bordered  by  fine 
granulations. 

Eggs  are  elliptic,  with  a  thin,  clear  yellow  shell,  with  granular  contents 
about  0.00675  by  0.0375  mm.  They  hatch  quickly,  so  are  rare  in  the 
stools.  They  occur  chiefly  in  the  duodenum  and  jejunum,  but  have  been 
found  in  the  stomach  and  other  parts  of  the  intestines.  The  source  of 
infection  has  been  attributed  to  contaminated  food  or  drinking  water 
and  also  to  the  entrance  of  the  parasite  through  the  skin. 

Symptoms. — They   are   usually   more   of   chronic   diarrhea   than   of 
'  Med.  Rec,  April  6,  1907. 


Fig.  396.  —  Strongyloides 
intestinalis  and  stercoralis:  i. 
Larva  (Anguillula  intesti- 
nalis); 2,  male  Anguillula  ster- 
coralis; 3,  female  Anguillula 
stercoralis  (after  Perroncito). 


INTESTINAL    PARASITES  949 

dysentery.  There  are  at  first  mild  dyspeptic  symptoms,  eructations, 
anorexia,  and  a  diarrhea  of  moderate  intenstity,  with  soft  and  pasty  stools, 
three  or  four  a  day,  often  in  the  early  morning  hours.  The  attacks  are 
sometimes  dysenteric,  with  mucus  and  blood;  in  other  cases  they  are 
more  choleraic,  the  dejecta  consisting  of  liquid  yellow  material;  while 
vomiting,  cyanosis,  and  collapse  may  occur. 

Emaciation  and  prostration  may  be  present.  Anemia  though  pres- 
ent, is,  as  a  rule,  not  very  severe.  Intercurrent  dysentery  is  not 
uncommon,  also  headache,  vertigo,  tinnitus,  aurium,  and  prostration. 

In  India,  Powell  found  this  parasite  in  over  75  per  cent,  of  the  cases 
of  anemia.  In  incomplicated  cases  a  high  grade  of  leukocytosis  may  be 
present.  There  is  eosinophilia.  Some  patients  complain  of  diflScult 
breathing  and  of  painful  deglutition  and  Strong  describes  a  peculiar  facial 
expression  which  is  characteristic.  A  general  toxemia  may  be  produced 
by  the  toxins  of  these  parasites.  Moss^  reports  an  unusual  case  of  long 
duration,  suffering  from  attacks  of  dyspnea,  cyanosis,  frequent  and 
painful  urination,  burning  sensations  of  the  buttocks  and  thighs,  emacia- 
tion, quite  marked  anemia  and  sphincteric  spasm.  Eosinophilia  was  over 
12  per  cent.     The  case  resulted  fatally. 


Fig*  397- — Trichocephalus   dispar:   a,    Fe-  ^         Fig.    398. — Egg    of    Trichocephalus 
male;  b,  male  (natural  size)  (Heller).  dispar,  moderately  enlarged  (Heller). 

Treatment. — Rest  and  liquid  diet.  Male  fern,  ethereal  extract,  12  to 
30  grams  divided  in  three  doses  during  the  morning  and  repeated  daily, 
have  been  used  by  the  Italians. 

Thymol  has  been  quite  successful,  by  the  method  described. 

Large  quantities  of  olive  oil  have  seemed  to  give  good  results  in  some 
cases. 

Trichocephalus  Dispar  (Whip-worm). — This  parasite  is  found  in  the 
cecum  and  large  intestine  of  man.  It  measures  from  4  to  5  cm.  long,  the 
male  being  smaller  than  the  female.  It  is  readily  recognized  by  the 
peculiar  differences  between  the  anterior  and  posterior  portions.  The 
anterior  forms  three-fifths  of  the  body,  is  thin  and  hair-like;  the  tail  end 
of  the  female  is  more  conic  and  thicker,  terminating  in  a  blunt  extremity; 
while  that  of  the  male  is  rolled  like  a  spring  (Fig.  397). 

The  ovum  is  lemon  shaped,  dark  brown,  0.05  mm.  in  length,  and 
provided  with  button-like  projections  (Fig.  398). 

The  number  of  worms  is  variable,  as  many  as  a  thousand  having  been 
counted;  often  only  10  to  20  are  found.  In  parts  of  Europe  particularly 
in  Italy  they  are  very  common,  but  not  so  in  the  United  States.- 

Symptoms. — Profound    anemia    with    diarrhea    have    occurred    from 

'  N.  Y.  Med.  Jour.,  May  23,  1914. 

'  The  writer  has  seen  two  cases  in  New  York  City  recently  and  several  from  Cuba 
and  Central  America.    There  were  no  symptoms  imputed  to  the  parasites. 


950 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


them.  Many  worms  may  be  present  without  producing  symptoms; 
occasionally  diarrhea  and  nervous  symptoms  occur,  and  enteritis  has  been 
reported  as  due  to  this  parasite.  Dysentery,  aphonia,  perityphlitis  and 
;*'^omiting  of  blood  have  been  reported.^ 

Diagnosis. — This  can  be  made  from  the  peculiar  ova.  Living  worms 
are  rare  in  the  stool. 

Treatment. — Thymol,  as  previously  described.  Extract  of  male 
fern  may  be  employed.  High  enemata  of  warm  water,  i  quart  (liter), 
containing  5  to  lo  drops  of  benzin,  may  be  of  service. 

Trichina  Spiralis  (Trichiniasis). — The  trichina  in  its  adult  condition 
lives  in  the  small  intestine.  The  embryos  pass  from  the  intestines  and 
reach  the  voluntary  muscles,  where  they  become  encapsulated  larvae. 

Muscle  Trichina. — Tiedemann,  in  1822,  described  the  ovwd  cysts 
in  human  muscle.  Owen  named  the  parasite.  Leidy,  in  1845,  described 
it  in  the  pig.  In  i860,  Zenker  discovered  in  a  girl  both  the  intestinal  and 
muscle  forms,  and  established  their  connection  with  the  specific  symptoms. 


Fig.  399- 


-Trichina  spiralis  (greatly  enlarged):  a.  Female;  b,  male;  c,  embryo  (after 
Heller). 


Incidence. — Man  is  infected  by  eating  the  raw  or  not  completely  cooked 
flesh  of  trichinous  hogs,  which  contain  encapsulated  trichinae.  The 
capsules  are  digested  in  the  stomach  and  the  trichinae  set  free.  They  pass 
into  the  small  intestine,  and  about  the  third  day  become  sexually  mature. 
On  the  sixth  or  seventh  day  the  embryos  are  fully  developed.  The 
young  produced  by  each  trichina  (female)  have  been  estimated  at  several 
hundred.  The  female  worm  penetrates  the  intestinal  wall  and  the 
embryos  are  probably  discharged  directly  into  the  lymph-spaces,  and 
thence  into  the  venous  system,  whence  they  reach  the  muscles;  and  in  about 
two  weeks  they  develop  into  the  full-grown  muscle  form.  A  myositis 
is  produced  and  they  may  become  encapsulated.  The  trichinae  may 
live  therein  for  many  years.  Calcification  may  occur  about  them.  One 
must  remember  that  in  the  hog  the  capsule  does  not  readily  become 
calcified,  so  that  the  parasites  are  not  as  readily  visible  as  in  man.  More- 
over, an  apparently  healthy  looking  animal  may  be  suffering  from 
trichiniasis. 

Children  seem  to  suffer  slightly  from  the  disease.     Van  Cott*  holds 

^  Mellon,  Med.  Rec,  Aug.  21,  1915. 
*  Journal  A.  M.  A.,  Feb.  28,  1914- 


INTESTINAL    PARASITES 


951 


that  the  small  quantity  of  infected  meat  ingested  in  children  explains 
their   mild   attacks. 

The  intestinal  trichina  are  visible  to  the 
naked  eye — white  glistening  worms  3  to  4  mm. 
long;  and  the  male  half  this  size,  with  two 
little  projections  from  the  hind  end.  The 
caudal  extremity  is   thicker   than   the  head 

Fg-  399)- 

The  muscle  trichina  is  0,6  to  i  mm.  long 
and  coiled  in  the  capsule.  It  has  a  pointed 
head  and  rounded  tail  (Fig.  400). 

The  dead  parasites  are  probably  usually 
dissolved  in  the  small  intestine  and  dead  or 
living  appear  to  be  rarely  found  in  the  stool. 
The  embryos  are  exceptionally  discharged 
into  the  lumen  of  the  gut. 

Trichinella  Spiralis  in  the  Human  Blood. — 
Herrick  and  T.  Janeway^  have  demonstrated 
the  Trichinella  spiralis  in  the  human  blood, 

and  E.  Packard^  reports  finding  an  embryo  of  the  Trichinella  spiralis  in  the 
blood  of  a  patient  and  within  a  short  period  larger  embryos  in  the  muscle, 
not  yet  encysted  (Figs.  401  and  402). 


I'lg.  400. — Fresh  muscle  trich- 
inae (Mosler  and  Peiper). 


Fig.  401. — Trichinella  spiralis  in  blood  (  X  500)  (Packard). 

Trichince  in  the  Cerebrospinal  Fluid. — Van  Cott^  and  Lintz  discovered 
living  trichinae  in  the  cerebrospinal    fluid    by    lumbar    puncture.     No 

1  Arch.  Int.  Med.f  1909,  iii,  263. 

*  Jour.  Amer.  Med.  Assoc,  April  16,  1910. 

^  Journal  A.  M.  A.,  Feb.  28,  1914. 


952 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


trichinae  were  found  in  the  blood  of  this  patient  and  they  were  believed  to 
be  probably  present  in  the  nerve  tissue  and  to  be  derived  in  the  spinal 
fluid  from  that  source.     Bloch^  also  reports  a  case  and  Lintz,^  3  cases. 

Development  of  Toxins. — Ilury^  has  demonstrated  that  poisonous 
products  arise  in  connection  with  the  evolution  of  the  trichinae  just  as 
certain  other  intestinal  parasites  liberate  toxic  substances.  Chemical 
products  also  arise  from  the  invaded  and  damaged  muscle  tissue.  The 
trichinae  infected  muscle  cells  are  profoundly  altered,  there  being  an 
undue  accumulation  of  certain  purin  compounds.  Trichinosed  muscle 
contains  highly  active  poisons  which  can  provoke  rigor  and  tonus  and 


Fig.  402. — Trichinella  spiralis  found  in  muscle  five  days  after  embryo  was  found  in 
blood  (X  about  250)  (Packard). 

derivatives   of   the   guanidin   series   may   produce   nervous   symptoms. 

Flury*  has  initiated  and  imitated  varied  symptoms  of  trichinosis  in  animals 

by  feeding  them  with  the  toxic  extracts  of  trichinosed  flesh.     Herrick^ 

believes  the  fever  due  to  parenteral  introduction  of  alien  protein  material. 

Symptoms. — As  a  rule,  a  few  days  after  eating  the  infected  flesh 

gastro-intestinal  disturbances  occur,  such  as  pain  in  the  abdomen,  anorexia, 

vomiting,  and  severe  diarrhea.     The  attack  may  resemble  cholera  nostras 

or  even  typhoid  fever.     Invasion  symptoms  usually  occur  between  the 

seventh  and  tenth  days  or,  occasionally,  not  until  the  end  of  two  v/eeks. 

There  may  be  fever,  intermittent  or  remittent,  even  to  102°  to  io4°F. 

Chills  are  not  common. 

^  Ibid,  Dec.  18,  1915. 

^  Ibid,  June  10,  19 16. 

'  Arch.  f.  exper.  Path.  u.  Pharmakol.,  1913,  Ixxiii,  164  and  214. 

*  Arch.  f.  exper.  Path.  u.  Pharmakol,  1913,  Ixvii,  294. 

^Journal  A.M. A.,  Nov.  27,  1915 


INTESTINAL    PARASITES  953 

Pain  occurs  in  the  muscles  on  pressure  and  movement,  also  swelling 
of  the  muscles.  There  may  be  difficulty  in  chewing  and  swallowing. 
Respiration  may  be  painful.  Dyspnea  may  be  present  from  involvement 
of  the  intercostal  muscles  and  diaphragm.  Edema  of  the  face,  especially 
about  the  eyes,  is  an  important  symptom.  Sweating,  itching,  and  urticaria 
occur.  There  may  be  capillary  hemorrhages.  The  general  nutrition  is 
disturbed  and  the  patient  becomes  anemic  and  emaciated.  In  cases  with 
severe  infection,  there  may  be  delirium,  tremor,  and  dry  tongue,  sug- 
gestive of  typhoid  fever.  Bronchitis,  pleurisy,  pneumonia,  polyuria,  or 
albuminuria  may  occur.  No  splenic  enlargement.  Diazo  reaction 
positive. 

In  Van  Cott's  cases,  there  were  headaches,  loss  of  patellar  reflex,  and 
sometimes  the  loss  of  Achilles  tendon  reflex,  with  Kernig's  sign  present 
almost  invariably  and  a  rigid  neck.  Dilatation  of  the  pupils  was  marked 
in  the  fatal  cases  and  was  present  from  the  beginning  of  the  disease. 

Differential  Diagnosis. — Trichinosis  has  been  mistaken  for  typhoid 
fever  and  for  articular  or  muscular  rheumatism,  multiple  neuritis,  or 
cholera  morbus.  With  tj^hoid  there  is  leukopenia,  the  presence  of  the 
Widal  reaction,  enlarged  spleen,  and  the  typhoid  temperature.  The 
typhoid  bacilli  are  also  present  in  the  blood  and  stools.  With  nephritis, 
there  are  edema,  gastro-intestinal  symptoms,  and  urinary  findings  of  such 
but  no  eosinophilia. 

With  cerebrospinal  meningitis  we  have  positive  Kernig's  sign,  exagger- 
ated knee-jerks,  Achilles  tendon  reflex  but  no  eosinophilia,  while  with 
trichinosis  there  are  Kernig's  sign,  loss  of  patellar  reflex,  absence  of 
Achilles  tendon  reflex,  eosinophilia  and  the  muscle  symptoms. 

Leukocytosis,  especially  marked  eosinophilia,  is  an  aid  to  the  diagnosis 
of  trichinosis.  There  is  often  secondary  anemia.  Charcot-Leyden  crystals 
occur  in  the  stools. 

Eosinophilia,  edema  of  the  eyelids,  dyspnea,  swelling,  and  tension  of 
the  muscles  are  at  once  suggestive.  The  presence  of  trichinae  in  the 
stools  and  muscles  is  conclusive.  The  muscle  can  be  incised  under 
cocain  injection  and  the  cyst  examined. 

The  disease  has  proved  fatal  in  a  number  of  cases. 

Prognosis. — This  depends  on  the  intensity  of  the  infection.  Mild 
cases  may  recover  in  two  weeks.  The  mortality  has  ranged  as  high  as 
30  per  cent.     Early  diarrhea  is  favorable  to  evacuate  the  infected  pork. 

Prophylaxis. — Pork,  such  as  ham,  sausage,  etc.,  should  always  be 
thoroughly  cooked  before  eating.     Proper  inspection  of  hogs  is  important. 

Treatment. — Immediate  lavage,  if  infected  pork  is  suspected  and  the 
case  is  seen  early.  Evacuation  of  the  bowel  by  calomel,  lo  grains  (0.6), 
or  a  saline  cathartic.  Thymol,  santonin,  male  fern,  kamala,  and  turpen- 
tine, have  all  been  recommended  as  vermifuges  in  the  early  stage  but  have 
not  proved  particularly  satisfactory.  Colonic  irrigations  with  various 
anthelmintics,  irrigation  with  weak  benzin,  etc.,  would  not  reach  the 
small  intestine.  Van  Cott  has  experimented  with  salvarsan  and  neo- 
salvarsan  injections  with  apparently  no  beneficial  results.  Glycerin  in 
large  doses  internally  is  said  to  be  destructive  of  the  worm.  Later,  the 
treatment  is  symptomatic  and  the  strength  is  to  be  supported.     Hexa- 


954  DISEASES    OF   THE   STOMACH   AND   INTESTINES 

methylenamin  in  lo-grain  (0.6)  doses  six  to  eight  times  a  day,  I  believe 
of  value  during  the  early  stages.  It  is  preferable  to  combine  it  with  equal 
doses  of  sodium  benzoate.  In  view  of  the  presence  of  the  parasite  in  the 
blood  and  spinal  fluid,  this  method  seems  particularly  logical. 

The  writer  has  secured  an  excellent  result  by  the  use  of  hexamethyl- 
enamin  in  a  recent  case. 

Picric  acid,  J^  to  2  grains  (0.03-0.1)  dissolved  in  alcoholic  solution  and 
well  diluted,  has  been  recommended  to  destroy  the  larval  forms  circulat- 
ing in  the  blood.  It  is  very  bitter  and  liable  to  cause  gastro-intestinal 
irritation.  Quinin  has  also  been  recommended.  I  do  not  advise  their 
use. 


PART  IV 


DISEASES  OF  THE  PANCREAS 


CHAPTER  XXXVIII 


THE  PANCREAS  AND  ITS  ANOMALIES— SURGICAL 
RELATIONS 

The  greater  part  of  the  pancreas  is  located  in  the  epigastrium  (Fig. 
403),  but  a  portion  of  the  body  and  tail  extend  into  the  left  h3^ochondrium, 
and  the  head  may  project  into  the  umbilical  region.    The  organ  lies  about 


Fig.  403. — Surface  marking  of  the  pancreas. 

3  inches  above  the  umbilicus,  midway  between  the  navel  and  ensiform 

appendix,  the  body  corresponding  to  the  level  of  the  first  lumbar  vertebra. 

To  expose  the  pancreas  one  must  detach  the  stomach  from  the  great 

omentum  and  turn  it  upward.    The  pancreas  is  a  long,  pink,  cream-colored 

955 


956 


DISEASES   OF    THE    STOMACH   AND   INTESTINES 


gland,  which  stretches  transversely  across  the  posterior  abdominal  wall 
from  the  concavity  of  the  duodenum  to  the  lower  and  inner  border  of  the 
spleen  (Fig.  404). 

When  fresh,  its  consistency  is  firm  and  its  appearance  is  lobulated. 
It  varies  in  length  from  5  to  6  inches  (12  to  15  cm.).  Its  weight  averages 
from  2.25  to  3.5  ounces  (66  to  102  gm.). 

The  enlarged  right  extremity,  or  "head,"  extends  downward  and  to 
the  left,  and  lies  in  the  concavity  of  the  duodenum,  in  contact  with  its 
second  and  third  parts.  This  portion  is  enlarged,  bulbous,  and  lies 
opposite  the  second  and  upper  part  of  the  third  lumbar  vertebra.  The 
short  constricted  part,  or  "neck,"  arises  from  the  upper  and  anterior 
part  of  the  head.     It  runs  upward  and  slightly  forward,  and  then  to  the 


Inferior 
vena  cava     Aorta 


Stomach 


Left  adrenax 


Right  adrenal 


Right 
kidney 


Spleen 


Kidney 


Colon 


Colon 


Fig.  404. — Diagram  showing  the  relations  of  the  pancreas  (Robson  and  Cammidge). 


left  for  about  an  inch,  where  it  merges  into  the  body  of  the  gland.  This 
last,  which  is  the  longest  section,  runs  backward  and  to  the  left  at  the 
level  of  the  first  lumbar  vertebra.  The  pointed  left  extremity  ("tail") 
is  least  firmly  attached,  and  it  merges  gradually  into  the  body. 

To  the  left  of  the  head,  in  contact  with  the  neck,  is  a  deep  groove,  the 
"incisura  pancreatis,"  in  which  lie  the  superior  mesenteric  vessels;  a 
short  process  of  the  head,  the  "uncinate,"  projects  behind  and  to  the  left 
of  the  vessels  along  the  third  part  of  the  duodenum,  deepening  the  groove 
in  which  they  lie.  Occasionally  this  process  lies  separate  and  is  known 
as  the  "lesser  pancreas." 

The  anterior  aspect  of  the  head  is  in  contact  with  the  commencement 
of  the  transverse  colon.  The  liver  overlaps  the  pancreas.  The  lower 
part  of  the  head  anteriorly  is  covered  by  peritoneum  reflected  from  the 


THE    PANCREAS    AND    ITS    ANOMALIES — SURGICAL    RELATIONS        957 

lower  surface  of  the  colon,  and  which  enters  into  the  formation  of  the 
greater  sac  of  the  peritoneum.  This  part  is  in  contact  with  the  small 
intestine. 

The  posterior  surface  of  the  head  has  no  peritoneal  coat,  and  lies 
in  front  of  the  inferior  vena  cava,  the  left  renal  vein,  and  the  aorta.  The 
common  bile-duct  is  in  a  groove  or  canal  on  this  surface. 

Anteriorly,  and  to  the  right,  the  neck  is  in  contact  with  the  first  part 
of  the  duodenum,  and  with  the  pylorus  when  the  stomach  is  distended. 
Behind,  and  to  the  left,  there  is  a  groove  in  which  are  the  terminations 
of  the  superior  mesenteric  veins  and  splenic  veins. 

The  body  has  three  surfaces.  Its  anterior  surface  is  concave,  looking 
upward  and  forward.  The  lesser  sac  of  the  peritoneum  separates  it  from 
the  stomach.  Where  the  body  joins  the  neck  there  is  often  a  prominence 
- — ^the  "omental  tuberosity" — so  called  from  its  contact  with  the  small 
omentum  when  the  stomach  is  distended.  The  posterior  surface  looks 
backward  and  lies  upon  the  aorta,  the  origin  of  the  superior  mesenteric 
artery,  the  pillars  of  the  diaphragm,  the  splenic  artery  and  vein,  the  left 
kidney  and  renal  vessels,  and  the  left  suprarenal  capsule.  The  splenic 
vessels  run  along  its  upper  border  in  a  single  groove  or,  at  times,  in 
separate  grooves.  The  posterior  surface  has  no  peritoneal  covering,  and 
is  connected  to  the  abdominal  wall  and  adjacent  organs  by  areolar  tissue. 
The  inferior  surface  looks  downward  and  slightly  forward.  At  the  right 
end  it  rests  on  the  duodetwjejimal  flexure.  The  middle  part  is  covered  by 
jejunum.  This  surface  is  invested  by  peritoneum  derived  from  the 
descending  layer  of  the  transverse  mesocolon.  With  gastroptosis,  the 
pancreas  may  at  times  be  felt  in  a  space  between  the  edge  of  the  liver  and 
the  lesser  curvature  of  the  stomach. 

The  tail  is  in  contact  with  the  lower  part  of  the  inner  surface  of  the 
spleen,  but  occasionally  a  portion  of  the  mesentery,  containing  a  lymph- 
nodule,  intervenes. 

Blood-supply. — Arteries. — The  hepatic  branch  of  the  celiac  axis,  the 
inferior  pancreaticoduodenal  branch  of  the  superior  mesenteric,  the 
superior  pancreaticoduodenal  artery  (a  branch  of  the  gastroduodenal), 
and  branches  of  the  splenic  and  of  the  hepatic  arteries  supply  the  pancreas. 

Veins. — These  are  tributaries  of  the  splenic  and  superior  mesenteric 
veins,  the  aiiierosuperior  pancreaticoduodenal  vein,  which  enters  the 
superior  mesenteric  vein;  the  posterior  pancreaticoduodenal  vein,  which 
empties  into  the  portal  vein;  a  number  of  small  tributaries  enter  the 
splenic  vein,  and  small  veins  from  the  head  and  neck,  which  run  into  the 
portal  vein. 

Ljntnphatics. — This  system  enters  into  glands  located  on  the  head  of 
the  pancreas,  in  the  hilum  of  the  spleen,  and  along  the  superior  mesenteric 
vessels. 

Nerves. — The  vagi  supply  the  cerebrospinal  fibers,  and  the  solar 
plexus  the  sympathetic  fibers.  They  accompany  the  arteries  through 
the  celiac,  splenic,  and  superior  mesenteric  plexuses,  traverse  the  substance 
of  the  gland  in  company  with  the  ducts,  and  terminate  in  plexuses  around 
the  acini,  sending  fibers  to  the  secreting  cells.  The  nerve-fibers  are 
chiefly  non-medullated,  and  have  minute  visceral  sympathetic  ganglia. 


958  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

Small  nerve-cells  are  also  found  near  the  distribution  of  the  nerve-fibers 
to  the  alveoli. 

Peritoneum. — The  transverse  mesocolon  is  attached  to  the  anterior 
border  of  the  pancreas,  from  the  neck  to  the  tail.  The  anterior  layer 
passes  upward  and  backward  over  the  superior  surface,  forming  the  pos- 
terior wall  of  the  lesser  peritoneal  cavity.  The  posterior  layer  passes 
downward  and  backward  along  the  inferior  surface  to  form  the  greater 
peritoneal  sac.  At  the  neck  and  on  the  head  anteriorly  the  two  layers 
of  peritoneum  have  separate  lines  of  attachment,  so  that  there  is  a 
space  devoid  of  peritoneal  covering,  which  is  separated  from  the  colon 
by  areolar  tissue.  In  some  cases  the  transverse  mesocolon  is  continued 
as  far  as  the  hepatic  flexure,  in  which  event  the  head  and  neck  are  com- 
pletely invested.  The  posterior  surface  of  the  pancreas  is  uncovered  by 
peritoneum. 

Ducts  of  the  Pancreas. — The  pancreas  has  two  ducts  opening  sepa- 
rately into  the  duodenum.  The  duct  of  Wirsung,  the  chief  one,  commences 
in  the  tail  from  the  union  of  the  small  branches  and  gradually  increases  in 
size,  passing  through  the  body  of  the  gland  from  left  to  right.  It  passes 
downward  and  backward  through  the  neck  into  the  head  of  the  organ, 
where  it  lies  nearer  the  posterior  surface,  and  is  in  relation  with  the  com- 
mon bile-duct,  beside  which  it  runs  into  the  duodenum.  The  two  ducts 
pierce  the  second  part  of  the  duodenum  obliquely,  about  3  to  4  inches 
(8  to  12  cm.)  below  the  pylorus,  and  afterward  unite  to  form  a  common 
channel,  the  "ampulla"  or  "diverticulum  of  Vater,"  which  opens  by  an 
orifice  into  the  gut.  This  last  is  situated  on  a  papilla-like  fold  of  the 
mucous  membrane,  called  the  "papilla  or  caruncula  major."  Above  it 
there  is  a  small  fold  of  mucous  membrane,  which  must  be  raised  in  order 
that  the  orifice  may  be  seen.  Running  downward  from  the  caruncle  there 
is  a  small  vertical  fold  known  as  the  "frenum  carunculae"  or  "plica 
longitudinalis," 

The  diverticulum  of  Vater  is  oval  or  triangular,  having  the  duodenal 
orifice  at  its  apex,  and  its  base  at  the  openings  of  the  two  ducts.  Its 
average  length  is  only  3.9  mm.,  though  Testut  believes  it  to  be  longer, 
from  6  to  7  mm.,  and  rarely  as  much  as  11  mm.  The  orifice  of  the 
diverticulum  of  Vater  is  the  narrowest  part  of  the  biliary  channel,  only 
averaging  2.5  mm.  According  to  Oddi,  a  thin  layer  of  unstriped  muscle- 
fiber  surrounds  the  ampulla  and  the  terminations  of  the  ducts,  forming  a 
sphincter. 

The  duct  of  Santorini  (ductus  pancreaticus  accessorius)  drains  a  large 
part  of  the  head  of  the  pancreas.  It  anastomoses  near  the  neck  with  the 
duct  of  Wirsung,  is  apparently  a  branch  of  this  larger  duct,  and  usually 
increases  in  size  as  it  approaches  it.  The  duct  of  Santorini  diminishes 
in  size  as  it  approaches  the  duodenum  and  opens  into  the  latter  on  a  small 
papilla,  the  "caruncula  minor,"  ^i  to  i  inch  above  and  ventral  to  the 
"papilla  major."  Opie  finds,  in  more  than  half  the  cases,  that  the 
orifice  of  the  duct  of  Santorini  is  obUterated,  or  so  constructed  that  it 
cannot  assume  the  function  of  the  larger  duct  when  the  latter  is  occluded. 
The  main  and  accessory  ducts  communicate  with  each  other  by  branches 
of  varying  size. 


THE    PANCREAS   AND   ITS   ANOMALIES — SURGICAL   RELATIONS        959 

ANATOMIC  ANOMALIES  OF  THE  PANCREAS 

Depending  upon  alterations  of  the  usual  process  of  development  various 
anomalies  may  occur  in  the  pancreas.  The  tail  of  the  pancreas  has 
occasionally  been  bifid. 

Pancreas  divisum  is  due  to  an  absence  of  lobules  of  parenchyma 
about  the  duct  of  Wirsung  or  its  branches  for  a  short  distance,  so  that 
a  division  of  the  gland  into  two  parts  may  result. 

Pancreas  Minus.— There  is  a  supernumerary  lobule  or  lobe  present 
in  the  head  of  the  gland,  separated  by  a  constriction.  It  cannot  be  classed 
as  an  accessory  pancreas,  as  it  is  merely  a  part  of  the  pancreas  which  is 
separated  from  the  remainder  by  a  depression  more  marked  than  usual. 
The  portion  of  the  head  l)dng  behind  the  mesenteric  vessels  is  an  ex- 
ample.    It  forms  the  lesser  pancreas  (pancreas  parvum). 

Annular  Pancreas. — In  rare  cases  the  whole  circumference  of  the 
duodenum  is  enclosed  in  a  ring  of  pancreatic  tissue.  It  may  be  congenital 
or  a  result  of  invasion  of  the  head  of  the  gland  by  a  growth  or  from  inflam- 
matory changes.  It  may  cause  partial  obstruction  with  dilatation  of  the 
duodenum  above  the  point  of  constriction,  and  usually  dilatation  of  the 
stomach  with  hypertrophy  of  its  wall.  The  patient  suffers  from  symptoms 
similar  to  pyloric  stenosis. 

Pancreas  Accessorium  {Aberrant  Pancreas). — An  accessory  pancreas 
is  a  mass  of  pancreatic  tissue  entirely  separated  from  the  pancreas  and 
having  a  duct  of  its  own.  Possibly  such  isolated  masses  of  gland  tissue 
may  vicariously  assume  the  function  of  the  main  organ  when  diseased, 
and  they  may  cause  diverticula  or  herniae  of  the  wall  of  the  intestines. 
Opie^  reports  10  cases  in  1800  autopsies,  which  he  divides  into  two  groups, 
those  lying  above  the  pancreas,  in  the  duodenum  and  stomach,  and 
those  below,  in  the  duodenum  and  jejunum. 

Accessory  pancreas  has  also  been  found  in  the  ileum  in  an  umbilical 
fistula,  in  the  mesentery  of  the  duodenum,  and  in  the  fat  of  the  great 
omentum. 

The  aberrant  pancreas  averages  i  cm.  in  diameter,  though  it  has  been 
found  as  large  as  4.5  cm.  More  than  one  accessory  gland  may  occur  in 
the  same  person.  About  one-third  of  these  glands  are  situated  in  the 
wall  of  the  stomach  in  the  submucosa  near  the  pylorus,  and  about  two- 
thirds  occur  in  the  intestinal  wall. 

In  the  latter  they  are  more  frequent  in  the  muscular  layer,  though 
they  are  also  found  in  the  submucosa.  The  tissue  of  the  aberrant  gland 
does  not  differ  in  histologic  features  from  that  of  the  pancreas. 

Among  the  pathologic  changes  affecting  accessory  pancreatic  tissue 
are  fat  necrosis,  chronic  interstitial  inflammation,  and  malignant  growth. 

There  are  a  number  of  cases  recorded  in  which  accessory  pancreas  is 
associated  with  a  diverticulum  of  the  intestine  occurring  in  the  jejunum 
ileum,  duodenum,  and  once  even  in  the  stomach. 

Such  diverticula  usually  occur  in  children  from  less  than  a  year  old 
to  those  of  fourteen  years.     Intestinal  obstruction,  acute  intraperitoneal 

*  J.  B.  Lippincott,  Diseases  of  the  Pancreas. 


960  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

inflammation,  hernia,  into  the  pancreas,  both  with  and  without  hemorrhagic 
necrosis,  have  all  resulted  from  these  diverticula. 

Other  Anomalies  of  the  Pancreas. — The  pancreas  may  fall  forward, 
or  there  may  be  a  congenital  displacement  of  the  head  of  the  gland 
associated  with  gastroptosis.  Wandering  spleen  may  drag  the  tail  of  the 
pancreas  into  an  abnorlnal  position.  The  pancreas  has  been  pushed  down 
by  tight  lacing,  and  has  been  forced  upward  by  retroperitoneal  tumors 
and  aneurysms  of  adjacent  vessels. 

A  movable  pancreas  in  a  man,  resulting  from  a  fall,  has  been  reported 
by  Dabrzyki,  which  gave  rise  to  symptoms  resembling  those  of  movable 
kidney.  It  has  also  been  met  with  in  hernial  sacs  in  umbilical  hernia 
(both  congenital  and  acquired).  Luther  reports  it  in  diaphragmatic 
hernia,  and  in  one  case  it  had  passed  through  a  rent  in  the  diaphragm 
into  the  thoracic  cavity. 

Anatomic  Variations  of  the  Pancreatic  Ducts  and  Conmion  Bile- 
ducts. — Variations  in  these  ducts  have  an  important  bearing  upon  the 
pathology  of  the  pancreas,  and  especially  on  pancreatitis. 

Common  Bile-duct. — The  common  bile-duct  is  divided  into  four 
portions:  the  supraduodenal,  the  retroduodenal,  the  pancreatic,  and  the 
intraparietal  or  interstitial  portion,  which  last  is  contained  in  the  wall  of 
the  duodenum. 

The  pancreatic  portion,  which  chiefly  concerns  us,  is  from  20  to  25 
mm.  long,  and  extends  fromxthe  lower  border  of  the  first  part  of  the  duo- 
denum to  where  it  penetrates  the  second  part  of  this  viscus.  It  is  closely 
applied  anteriorly  to  the  posterior  surface  of  the  head  of  the  pancreas. 
It  is  estimated  that  in  from  62  to  75  per  cent,  of  cases  this  portion  of  the 
common  duct  is  completely  embraced  by  the  head  of  the  gland  and  that  it 
runs  in  a  deep  groove  in  the  remainder. 

It  is  evident  that  when  the  duct  passes  through  the  substance  of  the 
gland  that  a  swelling,  or  interstitial  inflammation  of  the  head  of  the 
pancreas,  may  compress  and  even  lead  to  the  occlusion  of  the  common 
bile-duct. 

Variations  in  the  Ampulla  of  Vater  and  Terminations  of  the  Ducts. — 
Normally,  the  common  bile-ducts  and  duct  of  Wirsung  empty  into  the 
ampulla.  The  pancreatic  and  common  ducts  may  join  a  little  distance 
from  the  duodenum,  the  ampulla  be  absent,  and  the  united  ducts  open 
into  the  duodenum  by  a  small  flat,  oval  orifice;  or  the  ducts  may  open 
into  a  concave  fossa  in  the  duodenal  wall;  or  the  caruncle  is  well  developed, 
but  the  ampulla  is  absent,  and  the  two  ducts  open  side  by  side.  Opie 
found  this  latter  arrangement  in  about  11  per  cent,  of  cases.  Rarely  the 
common  duct  unites  with  the  duct  of  Santorini.  The  bile-duct  may  open 
by  a  circular  orifice  and  the  pancreatic  duct  embrace  the  bile-duct  like 
a  gutter  and  have  an  orifice  of  cresentic  shape. 

Variations  in  the  Pancreatic  Ducts. — Opie  investigated  a  series  of  100 
cases  and  found  both  ducts  present,  though  one  may  have  been  partially 
obliterated,  or  so  small  that  it  was  demonstrated  with  difl&culty. 

In  89  per  cent,  the  duct  of  Wirsung  is  the  main  excretory  channel  of 
the  pancreas,  and  in  21  per  cent,  the  duct  of  Santorini  was  obliterated 
near  its  termination. 


THE   PANCREAS    AND    ITS    ANOMALIES — SURGICAL   RELATIONS        96 1 

Opie  found  that  in  48  cases  out  of  100  it  was  possible  to  inject  fluid 
at  low  pressure  through  the  lesser  papilla  into  the  duct  of  Santorini. 
After  numerous  experiments  he  concluded  that  in  more  than  half  of  all 
cases  the  lesser  duct  is  obliterated  at  its  orifice,  or  so  constructed  that  it 
cannot  assume  the  function  of  the  larger  duct  when  the  latter  is  occluded. 

The  varying  relations  of  the  duct  of  Santorini  to  the  duct  of  Wirsung 
are  shown  in  Fig.  405. 


Fig.  405. — Diagram  to  show  the  variations  in  the  ducts  of  Wirsung  (W)  and  San- 
torini (S).     Broken  lines,  in  the  plane  of  the  interlobular  fissure  (after  Opie). 

It  must  be  remembered  that  the  duct  of  Santorini,  even  if  patent,  may 
be  compressed  by  a  gall-stone  passing  down  the  pancreatic  portion  of  the 
common  bile-duct. 

Three  ducts  have  been  found,  the  additional  one  being  an  accessory 
pancreatic  duct  opening  into  the  ampulla  of  Vater. 

SURGICAL  RELATIONS 

As  the  head  of  the  pancreas  is  in  intimate  relation  with  the  duodenum, 
disease  of  the  gland  may  readily  invade  the  small  intestine,  or  the  converse 
61 


962  DISEASES    OF   THE    STOMACH    AND    INTESTINES 

may  happen.  Cancer  of  the  head  of  the  pancreas  has  obliterated  the  duo- 
denum to  such  an  extent  as  to  call  for  a  gastro-enterostomy.  Malignant 
growth  of  the  duodenum  may  invade  the  pancreas  and,  finally,  give  rise 
to  diabetes. 

Cysts  or  tumors  of  the  pancreas  may  compress  the  duodenum,  or 
the  latter  may  be  involved  in  a  pancreatic  abscess  which  may  discharge 
into  the  gut. 

The  stomach  lies  in  front  of  the  pancreas,  so  that  the  latter  is  liable 
to  invasion  from  ulcer  or  cancer  of  the  former.  Adhesions  between  the 
pancreas  and  stomach,  no  matter  which  organ  is  the  source  of  the  trouble, 
may  produce  symptoms  when  the  stomach  is  distended  with  food,  owing 
to  the  limitation  of  the  movements  of  the  latter  organ,  and  pain  may  also 
result  from  interference  with  its  peristalsis. 

When  the  pancreas  is  invaded  by  or  becomes  adherent  to  a  malignant 
growth  of  the  stomach,  this  increases  the  danger  of  operation  on  the 
stomach  and  renders  the  return  of  the  disease  more  probable  after  removal. 

In  100  cases  of  pyloric  cancer,  Fenwick  found  the  pancreas  adherent 
in  six.  With  cancer  at  the  cardia,  out  of  100  cases  the  pancreas  was 
ad  herent  in  16,  and  when  the  cancer  was  present  in  the  lesser  airvature 
or  posterior  wall,  the  pancreas  was  adherent  in  19. 

Chronic  gastric  ulcer,  when  situated  posteriorly,  may  become  adherent 
to  the  pancreas  and  may  cause  pancreatitis  or  even  produce  a  pancreatic 
abscess.  The  latter  may  burst  into  the  stomach  and  discharge  therein, 
producing  at  the  same  time  an  acute  gastritis. 

On  account  of  the  retroperitoneal  position  of  the  pancreas,  in  case  of 
suppurative  pancreatitis,  pus  may  burrow  upward  to  the  diaphragm  and 
downward  toward  the  left  iliac  fossa.  Pus  in  some  cases  may  be  reached 
from  the  right  or  left  loin,  from  the  left  iliac  fossa,  or  between  ribs,  if  it 
presents  as  a  subdiaphragmatic  abscess. 

The  anterior  surface  of  the  pancreas  projects  into  the  lesser  sac  of  the 
peritoneum,  being  covered  by  its  posterior  layer.  This  cavity  may  be 
invaded  in  inflammatory  conditions  or  from  an  injury  to  the  gland. 
When  filled  with  fluids  it  may  be  mistaken  for  a  true  pancreatic  cyst. 
Tumors  of  the  tail  of  the  pancreas  and  pancreatic  cysts  in  this  region  are 
more  readily  extirpated  than  when  in  other  regions,  as  they  are  less  closely 
connected  with  great  vessels.  The  tail  of  the  gland  serves  as  a  pedicle. 
Section  and  closure  of  the  pancreatic  duct  results  in  chronic  inflammation 
of  the  parenchyma,  which  is  tributary  to  the  occluded  duct,  and,  hence, 
injury  to  the  pancreas  is  greatest  in  proportion  to  the  nearness  of  the 
traumatism  to  the  duodenum. 

As  the  pancreas  lies  at  the  back  of  the  abdominal  cavity,  operation 
upon  it  is  not  particularly  easy,  and  various  routes  are  adopted  according 
to  indications.  One  must  also  remember  its  relations  to  the  vena  cava, 
the  aorta,  celiac  plexus,  spleen,  the  left  suprarenal  capsule,  the  left  kidney, 
portal  vein,  the  common  bile-duct,  and  middle  colic  artery.  The  usual 
method  to  expose  the  pancreas  is  through  the  gastrocolic  ligament,  entering 
the  lesser  peritoneal  cavity  between  the  stomach  and  transverse  colon.  If 
the  stomach  has  sunk  downward  and  the  lesion  is  near  the  upper  border 
of  the  pancreas,  incision  may  be  made  through  the  gastrohepatic  omentum. 


THE   PANCREAS    AND   ITS   ANOMALIES — SURGICAL   RELATIONS    963 

In  some  cases  one  may  push  up  the  omentum  and  transverse  colon  and 
reach  the  pancreas  by  incision  through  the  lower  layer  of  the  mesocolon. 
One  may  reach  the  head  of  the  pancreas  for  the  purpose  of  pancreatic 
lithotomy  or  to  examine  that  part,  by  incising  the  peritoneal  covering  of 
the  duodenum  and  forcing  a  way  along  its  side  to  the  head  of  the  pancreas. 
To  reach  the  posterior  surface  of  the  head  of  the  gland  in  order  to  expose 
the  pancreatic  portion  of  the  common  bile-duct  one  can  detach  the 
duodenum  from  the  abdominal  wall  and  lift  it  inward,  separating  it  from 
the  front  of  the  kidn,ey.  Under  some  conditions  extraperitoneal  operation 
may  be  employed;  thus,  an  abscess  of  the  tail  has  been  opened  through  the 
left  lumbar  region,  and  a  cyst  projecting  to  the  right  from  the  head  of 
the  pancreas  has  been  opened  in  the  right  lumbar  region. 


CHAPTER  XXXIX 
HISTOLOGY  OF  THE  PANCREAS— PHYSIOLOGY 

The  pancreas  consists  of  lobules  held  together  by  connective  tissue. 
It  is  composed  of  branching  ducts,  terminating  in  acini  that  are  round 
or  oval  (Maziarski).i 

The  acini  about  the  terminal  ducts  are  grouped  together  to  form 
primary  lobules  from  i  to  2.5  mm.  in  diameter.  These  last  are  not  so 
regularly  arranged  or  so  clearly  defined  from  each  other  by  connective 
tissue  as  in  animals,  and  may  be  indistinctly  marked  off,  and  even,  in 
places,  fuse  with  each  other. 

An  island  of  Langerhans  is  often  situated  in  the  middle  of  the  lobule. 

Numerous  primary  lobules  fuse  together  to  form  larger  secondary 
lobules,  which  last  are  separated  by  wide  bands  of  loose  areolar  tissue, 
in  which  are  contained  the  larger  ducts,  the  blood-vessels,  and  the  nerves. 

They  give  to  the  gland  its  lobulated  appearance.  They  vary  in  width 
irom  2  to  6  mm. 

The  arteries  and  veins  lying  side  by  side  do  not  accompany  the  ducts. 
Numerous  secondary  lobules  grouped  together  form  tertiary  lobules. 
They  represent  the  largest  subdivisions  on  the  surface  of  the  gland. 

Connective-tissue  Framework. — The  arrangement  of  the  connective- 
tissue  framework  of  the  pancreas  is  important,  in  view  of  the  changes 
which  occur  as  a  result  of  chronic  inflammation.  The  surface  of  the  gland 
has  no  capsule,  but  is  covered  by  a  thin  coat  of  connective  tissue.  Within 
the  substance  of  the  organ  the  connective  tissue  is  arranged  in  an  inter- 
lobular framework  which  separates  the  lobes  and  lobules,  and  also  an 
intralobular  network  of  fine  fibrils  which  pass  between  the  individual  acini 
and  form  a  plexus.  The  interlacing  fibers  form  a  reticulated  basement- 
membrane  which  supports  the  alveolar  cells  (Fig.  406).  Near  the  islands 
of  Langerhans  the  processes  between  the  alveoli  become  thicker  and  form 
septa  which  run  into  the  capsule  of  the  island. 

A  small  amount  of  elastic  tissue  is  mixed  with  the  fibrous  framework, 
chiefly  in  the  interlobular  regions.  The  ducts  throughout  are  surrounded 
by  a  fine  network  of  elastic  fibers. 

The  connective  tissue  contains  some  fat  and  connective-tissue  cells. 
Mast  cells  are  found  in  the  interlobular  framework.  Cells  with  polygonal 
or  elongated  nuclei  lie  in  the  interalveolar  connective  tissue. 

The  lobules  do  not  have  a  definite  hilus,  but  the  blood-vessels  and  ducts 
enter  separately. 

Ducts. — The  duct  of  Wirsung  while  passing  through  the  gland  gives 
off  lateral  branches,  most  numerous  on  its  upper  and  lower  aspect,  which 
usually  enter  the  main  channel  obliquely.  The  branches  subdivide  and 
give  off  lateral  twigs,  which  ultimately  penetrate  the  tertiary  lobules. 

^  Anat.  Hefte,  1901,  Hfte,  Iviii,  171. 
964 


HISTOLOGY    OF    THE    PANCREAS — PHYSIOLOGY  965 

The  pancreatic  ducts  and  their  large  branches  have  a  wall  of  connective 
tissue  containing  both  white  and  elastic  fibers,  and  lined  by  columnar  cells. 
Some  believe  these  cells  discharge  a  secretion  which  mixes  with  that  of  the 
alveoli.  In  the  wall  of  the  duct  of  Wirsung  there  are  structures  having 
the  character  of  mucous  glands.  The  medium-sized  ducts  within  the 
secondary  lobules  have  little  connective  tissue  in  their  walls,  and  are  lined 
by  cubic  or  low  cylindric  cells;  the  smallest  ducts,  about  which  the  acini 
are  grouped,  are  formed  by  a  layer  of  flat  epithelium  with  a  large  oval 
nucleus.    They  appear  spindle  shaped  on  longitudinal  section. 

B'  ^    - 
f-w    ■ 


[sland 


Fig.  406. — Piece  digestion  of  a  human  pancreas,  showing  the  limiting  membrane 
of  a  lobule  and  the  reticulated  basement-membranes  of  the  alveoli.  In  the  center 
is  an  island  of  Langerhans  with  its  capsule  of  trabeculae  (X  26)  (after  Flint). 

Acini. — The  shape  of  the  acini  varies  in  different  animals.  In  the 
human  pancreas  they  are  round  or  oval,  and  at  times  have  a  lobed  surface. 
They  do  not  branch. 

The  cells  forming  an  acinus  are  shaped  like  a  truncated  pyramid  with 
the  apex  toward  the  lumen  of  the  acinus  (Fig.  407).  They  constitute  the 
secreting  cells. 

The  apical  zone  contains  refractive  zymogen  granules.  There  is  a 
basal  zone,  which  is  homogeenous  except  for  striations  parallel  with  the 
long  axis  of  the  cell. 

The  granules  of  the  apical  zone  stain  with  certain  acid  dyes,  while 
the  protoplasm  of  the  base  stains  deeply  with  hematoxylin.  There  is  a 
nucleus  situated  near  the  base  of  the  cell.  It  is  a  spheric  or,  occasionally, 
oval,  and  has  a  well-defined  nuclear  membrane.  There  is  usually  a  large 
nucleolus. 

The  centro-acinar  cells  lie  in  the  acini  in  contact  with  the  apices  of  the 
secreting  cells.  They  are  fusiform,  occasionally  flat,  and  may  have  short 
projections  penetrating  between  the  secreting  cells.  The  protoplasm  is 
nearly  homogeneous  and  the  nucleus  is  small,  oval,  and  rich  in  chroma- 
tin. These  cells  resemble  those  of  the  terminal  ducts,  with  which  they 
seem  to  be  continuous.  There  are  at  times  scattered  fat  drops  in  the 
acini. 


966 


DISEASES   OF    THE    STOMACH   AND   INTESTINES 


Changes  with  Secretion. — Haidenhain^  has  demonstrated  in  dogs  that 
changes  occur  in  the  cells  of  the  acini  during  the  period  of  active  secretion 
of  the  pancreas.  From  six  to  ten  hours  after  a  full  meal  the  inner  zone, 
which  contains  the  granules,  decreases  in  size  until  it  occupies  only  the 
tip  of  the  cell.  The  outer  zone  increases  in  height,  but  not  as  rapidly  in 
proportion  as  the  inner  zone  decreases,  hence,  the  cell  becomes  smaller. 

From  the  tenth  to  the  twentieth  hour  after  food  the  cell  increases  in 
volume,  the  apical  zone  increases  in  size  through  accumulation  of  granules, 
and  the  basal  zone  diminishes  in  size. 

In  the  active  or  "discharged"  gland  the  granules  are  comparatively 
scanty,  while  in  the  resting  stage  they  are  abundant,  and  the  precursor  of 
trypsin  is  abundant  in  the  gland  of  a  fasting  animal. 


Outer  zone  of 
secretory  cells 


Connective  tissue  - 


Larger  glands_ 
duct 


-  Centro-acinal  ctSl 


Centro-acinal  cell 


Intermediate 
tubule 

Inner  granular 
zone  of  secre- 
tory cells 


Fig.   407. 


-From  section   through   human  pancreas;   X  450   (sublimate)    (Bohm  and 
Davidoff). 


Islands  of  Langerhans. — These  structures  (Fig.  408),  also  known  as 
the  interacinar  islands,  are  usually  round  or  oval,  and  their  outUnes  are 
frequently  defined  by  a  circle  of  thin  connective  tissue. 

In  others  the  shape  is  less  clearly  defined.  Their  size  may  be  from 
75  to  175  microns  in  diameter  and  occasionally  as  large  as  0.5  mm. 
DeWitt-  estimates  that  their  tissue  constitutes  from  K25  to  J45  oi  the 
total  volume  of  the  pancreas. 

Opie^  finds  that  the  islands  of  Langerhans  are  more  numerous  in  the 
splenic  end  or  tail;  in  all,  slightly  less  than  three  and  a  half  times  more 
numerous  in  these  regions  than  in  other  parts  of  the  pancreas. 

Position  of  the  Islands. — This  is  not  constant,  though  they  are  most 
frequently  situated  in  the  center  of  a  lobule. 

1  Arch.  f.  d.  ges.  Physiol.,  1875,  x,  557. 
*  Jour,  of  Exper.  Med.,  1906,  viii,  193. 
^  Johns  Hopkins  Bulletin,  1900,  xi,  205. 


HISTOLOGY   OF   THE   PANCREAS — PHYSIOLOGY 


967 


Cells  of  the  Island  of  Langerhans. — The  cells  are  polygonal,  and  are 
smaller  than  those  of  the  acini.  They  have  a  large  round  or  an  oval 
nucleus,  with  several  nucleoli.  The  cell  body  is  usually  well  defined. 
They  are  unstained  by  nuclear  dyes,  unlike  the  secreting  cells  of  the 
acini,  while  with  eosin  their  protoplasm  stains  a  bright  pink.  The  nuclei 
vary  in  size,  and  occasionally  very  large  nuclei  are  found,  larger  than  the 
adjacent  cells. 

The  cells  lie  in  columns,  between  which  there  are  anastomosing 
capillaries,  though  at  times  they  are  packed  together,  and  the  nuclei  lie 
side  by  side. 

Fat  droplets  are  found  in  the  islands  of  Langerhans. 


c? 


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0 


/0' 


'€. 


K  © 


©    ^-i  V       ®       O 


Fig.  408. — Island  of  Langerhans  of  the  human  pancreas   (Opie, 

Pancreas"). 


■  Diseases  of  the 


The  protoplasm  of  the  cells  of  the  island  is  not  entirely  homogeneous 
but  contains  small  granules,  staining  with  eosin,  safranin,  gentian  violet, 
and  f  uchsin. 

Lane^  has  demonstrated  two  varieties  of  cells,  one  soluble  and  the 
other  fixed  by  Miiller's  fluid  with  bichlorid. 

Blood-vessels. — The  capillaries  of  the  island  form  a  glomerulus  of 
tortuous  vessels  (Fig.  409)  which  freely  anastomose. 

A  single  afferent  vessel  does  not  enter  the  glomerulus,  as  it  does  in 
the  kidney.  There  are  numerous  anastomoses,  so  that  the  network 
within  the  island  is  continuous  with  the  capillaries  between  the  acini. 

There  is  no  evidence  in  the  human  subject  that  there  is  any  connection 
between  the  islands  and  the  duct  system  of  the  gland. 

Opie  holds  that  there  is  no  proof  that  any  transition  occurs  from  acini 
into  islands  of  Langerhans. 

>  Amer.  Jour,  of  Anat.,  1907,  vii,  40Q. 


968  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Intralobular  Framework. — The  connective  tissue  between  the  acini 
near  the  islands  of  Langerhans  becomes  thicker,  and  forms  septa  which 
run  into  the  capsule  of  the  island. 

The  capsule  is  composed  of  many  small  fibers,  which  are  connected 
on  the  one  side  with  the  alveolar  network,  and  on  the  other  with  septa, 
which  stretch  across  the  space  within  the  island,  subdividing  it  into  small 
lacunae,  and  which  act  as  a  support  for  its  cells. 

In  the  human  subject  the  age  and  the  condition  of  the  body  seem  to  be 
the  chief  factors  in  determining  the  amount  of  intra-insular  connective 
tissue. 

DeWitt  shows  that  in  the  pancreas  of  the  newborn  infant  there  is  no 
connective  tissue  in  the  islands ;  in  a  four-year-old  child  there  is  a  delicate 


Fig.  409. — Blood-vessels  of  the  pancreas  injected  in  order  to  show  the  glomerular 
arrangement  of  capillaries  in  the  islands  of  Langerhans  (Opie,  "Diseases  of  the  Pan- 
creas"). 

capsule  and  sheaths  surrounding  the  blood-vessels;  while  in  the  adult  the 
condition  was  found  as  described.  The  increase  accompanying  advancing 
age  suggests  the  condition  of  fibrosis,  which  occurs  in  other  organs  under 
similar  conditions. 

Function  of  the  Islands  of  Langerhans. — On  account  of  the  intimate 
relation  of  the  columns  of  the  epithelial  cells  of  the  islands  to  the  capillary 
network,  it  is  believed  the  islands  furnish  some  substance  to  the  blood, 
known  as  the  "internal  secretion  of  the  pancreas." 

A  study  of  the  pathologic  changes  associated  with  diabetes  mellitus 
has  shown  that  the  islands  of  Langerhans  control  the  assimilation  of 
sugar. 


HISTOLOGY  OF  THE  PANCREAS PHYSIOLOGY         969 

PHYSIOLOGY  OF  THE  PANCREAS 

The  Pancreatic  Juice. — The  pancreatic  juice  is  a  clear,  watery,  alka- 
line fluid,  without  odor,  with  a  specific  gravity  of  1.0075  to  1.0098.  It 
consists  of  approximately  98.5  water  and  1.5  solids.  One- third  to  two- 
thirds  of  the  solids  are  ash.  It  contains  a  small  amount  of  coagulable 
protein  and  enzymes,  which  play  an  important  part  in  the  digestion  of 
protein,  carbohydrates,  and  fat. 

The  gland  is  inactive  when  fasting.  Secretion  begins  directly  after 
a  meal  and  reaches  its  maximum  within  three  hours. 

The  quantity  and  character  of  the  pancreatic  juice  depends  on  the 
character  of  the  food.  Meat  causes  a  rapid  secretion  of  a  juice  poor  in 
solids,  while  bread,  a  slower  secretion,  but  in  greater  quantity.  Milk 
produces  the  flow  of  a  small  amount  of  concentrated  juice  with  a  low 
alkalinity. 

Cause  of  Pancreatic  Secretion. — Bayliss'  and  Starling,  isolating  a 
loop  of  the  jejunum  and  severing  all  its  nerve  connections,  the  blood- 
vessels only  remaining,  demonstrated  that  the  introduction  of  hydro- 
chloric acid  into  the  loop  produced  an  abundant  flow  of  pancreatic  juice. 
Evidently  some  chemic  substance  which  was  transported  by  the  blood 
from  the  loop  to  the  pancreas  caused  the  secretion.  Acid  introduced 
into  the  circulation  did  not  excite  secretion,  and  hence  it  was  evident  that 
acid,  introduced  into  the  intestines  caused  the  mucosa  of  that  viscus  to 
elaborate  some  substance  which  was  absorbed  by  the  blood,  was  carried 
to  the  pancreas,  and  thus  excited  its  activity. 

Moreover,  the  epithelial  cells  of  the  intestinal  mucosa  treated  with  the 
acid,  yielded  an  extract  which,  when  it  was  introduced  into  the  circulation, 
caused  an  active  flow  of  the  pancreatic  juice.  They  named  this  substance 
"secretin."  As  an  extract  of  the  cells  alone,  when  injected  into  the 
circulation,  did  not  produce  pancreatic  secretion,  it  was  evident  that  the 
acid  activated  some  substance  in  the  cells.    They  called  this  "  prosecretin." 

The  acid  evidently  converted  the  prosecretin  into  secretin,  which 
last  was  carried  by  the  circulation  and  excited  the  pancreas  into  activity. 

Pawlow  believed  that  nervous  mechanism,  stimulation  of  the  vagus, 
has  a  direct  influence  on  pancreatic  secretion.  Other  theories  have  also 
been  advanced,  but  the  work  of  Bayliss  and  Starling  is  considered  con- 
clusive. Fats  and  soaps  also  stimulate  pancreatic  secretion,  but  their  action 
is  less  marked.  Holsti^  through  experiments  on  a  man  with  pancreatic 
fistula  has  demonstrated  that  a  psychic  secretion  of  pancreatic  juice  occurs, 
just  as  it  does  with  the  gastric  juice,  though  it  plays  a  less  prominent 
part.  The  psychic  secretion  of  the  pancreas  independent  of  gastric 
causes  lasts  about  half  an  hour. 

The  epithelial  cells  of  the  duodenum  and  of  the  jejunum  chiefly 
contain  prosecretin.  Wertheimer^  and  Lepage  found  that  the  acid  caused 
the  greatest  flow  of  pancreatic  secretion  when  it  was  introduced  into  the 
duodenum;  a  less  intense  flow,  lower  in  the  small  intestine,  and  that  it 
disappeared  when  the  lower  part  of  the  ileum  was  reached.     Secretin  is 

*  Jour,   of  Physiol.,    1902,   xxviii,   325;   1903,   xxiv,   174. 

2  Deutsch  Arch.  f.  klin.  Med.,  1913,  cxi,  48. 

2  Jour,  de  Physical  et  de  Patholgen,  1901,  iii,  335. 


970  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

believed  to  influence  not  only  the  pancreatic  but  the  gastric  glands 
(through  gastrin)  and  to  stimulate  the  functional  activity  of  the  liver  and 
jejunum.  Some  hold  that  a  hormone  is  also  produced  by  the  spleen 
which  also  stimulates  the  digestive  glands. 

The  Ferments. — The  three  chief  ferments  of  the  pancreas  are  trypsin, 
amylopsin,  and  steapsin.  Some  claim  there  is  a  lab  ferment,  on  account 
of  the  ability  of  the  pancreatic  juice  to  coagulate  casein,  while  others 
impute  this  action  to  the  trypsin.  Other  observers  believe  there  is  a 
"lactase  ferment,"  because  of  its  supposed  power  of  splitting  milk-sugar 
into  galactose  and  dextrose. 

Nuclease. — Nucleic  acid  is,  for  the  great  part,  precipitated  in  the 
stomach  and  dissolved  in  the  intestines.  This  solution  of  the  nucleic 
acid,  which  is  caused  by  the  pancreatic  juice,  is  attributed  to  a  pancreatic 
enzyme,  "nuclease."^  Others  believe  it  to  be  simply  a  property  of 
trypsin. 

Trypsin. — Trypsin  does  not  exist  as  such  in  the  secreting  glands  of 
the  pancreas,  and  extracts  of  the  fresh  glands  do  not  act  upon  protein. 
It  is  beUeved  that  the  pancreas  contains  trypsinogen,  since  the  juice  which 
is  obtained  from  the  pancreatic  duct  after  the  use  of  secretin  contains  this 
enzyme.  The  intestinal  juice  (succus  entericus)  contains  an  enzyme 
"enterokinase,"  which  transforms  the  inactive  trypsinogen  into  active 
trypsin.  Pawlow,  on  the  other  hand,  claims  that  the  pancreatic  juice  of 
a  dog  fed  on  a  meat  diet  contains  trypsin. 

Trypsin  is  a  proteolytic  ferment,  and  not  only  forms  albumoses  and 
peptones  from  protein,  but  the  action  is  more  prolonged,  so  that  they 
are  transformed  into  amino-acids.  The  action  is  most  powerful  in  a 
weakly  alkahne  solution,  but  it  will  act  in  a  neutral  or  even  faint  acid 
medium.  Free  mineral  acids  destroy  the  ferment.  Organic  acids  are  less 
harmful. 

Collagen,  the  constituent  of  connective  tissue,  is  not  acted  on  by 
pancreatic  juice  unless  it  has  been  previously  boiled  with  water  or  has  been 
acted  on  by  dilute  acid,  hence,  connective  tissue  is  not  digested  if  the 
stomach  has  been  removed  or  if  the  secretion  of  the  acid  of  that  organ  is 
interfered  with. 

Gelatin  is  converted  into  gelatin  peptones  and  elastin  is  dissolved. 
Mucin  and  nucleoproteins,  after  preliminary  cleavage,  undergo  digestive 
changes.  Starling  has  shown  in  the  fasting  animal  that  a  mixture  of  the 
pancreatic  juice  with  the  intestinal  secretions  may  give  rise  to  inflamma- 
tion and  erosions  of  the  intestinal  wall.  In  the  case  of  pancreatic  fistula 
similar  effects  on  the  skin  are  produced. 

Steapsin. — The  digestion  of  fat  is  peculiarly  a  function  of ^the  pancreas. 
Neutral  fats,  we  must  remember,  owing  to  a  gastric  lipase  ferment,  undergo 
slow  changes  in  the  stomach,  and  fine  emulsions,  as  occurring  in  the  yolk 
of  eggs  and  milk,  are  more  completely  digested.  This  is  of  importance 
in  the  case  of  infants  before  the  lipolytic  function  of  the  pancreas  is 
developed,  and  also  in  adults  whose  pancreas  is  diseased. 

Steapsin,  the  fat-splitting  enzyme  of  the  pancreas,  acts  in  an  alkaline, 
neutral,  or  acid  reaction.    It  splits  neutral  fats  into  fatty  acids  and 
*  Umber,  Zeit.  f.  klin.  Med.,  1901,  xliii,  282. 


HISTOLOGY   OF    THE    PANCREAS — PHYSIOLOGY  971 

glycerin.  When  an  alkali  is  present,  the  fatty  acids  form  soluble  alkaline 
soaps.  These,  together  with  the  glycerin,  are  absorbed  by  the  epithelial 
cells  of  the  walls  of  the  intestines,  within  which  they  are  synthesized  to 
form  neutral  fat. 

Steapsin  can  also  decompose  a  number  of  esters  of  fatty  acids,  such 
as  ethyl-butyrate,  and  the  latter  can  be  used  as  a  test  for  the  presence  of 
the  fat-splitting  enzyme.  The  amount  of  acid  formed  measures  its 
activity.     The  action  of  the  enzyme  is  reversible.^ 

Bile  increases  the  activity  of  the  fat-splitting  enzyme  several  times. 
Its  method  of  action  is  unknown. 

Amylopsin. — This  is  an  amylolytic  enzyme  which  converts  starch 
into  dextrin,  and,  finally,  into  maltose.  Little,  if  any,  dextrose  is  formed 
from  starch,  and  invertin  is  not  produced.  Amylopsin  acts  in  the  presence 
of  a  weak  acid  and  is  somewhat  inhibited  by  a  weak  alkali.  Amylopsin 
is  not  present  in  the  pancreas  of  the  new-born  infant,  and  does  not  appear 
until  "more  than  a  month  after  birth. 

Autodigestion  of  the  Pancreas. — Self-digestion  of  the  pancreas  after 
death  of  the  subject  occurs  in  about  50  per  cent,  of  cases.  It  is  attributed 
to  the  proteolytic  enzyme. 

'  Kastle  and  Lovenhart,  Amer.  Chem.  Jour.,  1901,  xxiv,  491. 


CHAPTER  XL 

METHODS   OF  DIAGNOSIS  IN   PANCREATIC   DISEASE 

TESTING  THE  FUNCTIONS  OF  THE  PANCREAS 

The  pancreas  has  two  secretions,  an  internal  and  an  external.  The 
former  passes  into  the  blood  and  is  concerned  with  the  metabolism  of 
sugar.  It  also  appears  to  have  an  antagonistic  influence  on  the  secretion 
of  the  adrenals,  as  Loewi  has  shown  by  experiment  that,  in  dogs  whose 
pancreas  had  been  removed,  dilatation  of  the  pupil  took  place  after  instilla- 
tion of  adrenalin  into  the  eye.  The  external  secretion,  which  contains 
the  proteolytic,  fat-splitting,  and  amylolitic  ferments  (and,  as  some 
believe,  a  lab  ferment  and  nuclease),  will  first  be  referred  to  in  this  chapter. 

In  order  to  properly  test  the  digestive  capacity  of  the  pancreatic  juice, 
and  to  arrive  at  some  definite  conclusion  as  to  whether  this  organ  is 
suffering  from  a  temporary  disturbance  of  one  or  more  of  its  functions,  or 
whether  there  is  permanent  disability,  i.e.,  a  diseased  condition,  the  author 
believes  that  numerous  factors  must  be  taken  into  consideration,  and  that 
the  diagnosis  must  often  be  made  by  the  process  of  exclusion. 

Temporary  Disturbances  of  Function. — In  acute  febrile  conditions,  in 
typhoid  fever,  for  example,  there  is  a  disturbance  of  all  the  digestive  secre- 
tions, salivary,  stomach,  liver,  intestine,  and  pancreas.  As  a  result,  the 
digestive  function  of  the  pancreas  is  diminished.  This  has  been  previously 
referred  to  by  the  author  under  Typhoid  Fever,  and  is,  from  his  viewpoint, 
a  scientific  reason  for  the  avoidance  of  excessive  forced  feeding,  4500  to 
5500  calories,  during  the  active  stage  of  this  disease.  Duodenitis  may 
complicate  the  typhoid.  There  may  be  temporary  disturbances  of  the 
pancreas  for  any  one  or  for  all  of  the  functions,  to  which  reference  is  made 
under  Intestinal  Dyspepsia. 

Catarrh  of  the  duodenum  may  temporarily  disturb  the  functions  of  the 
pancreas  by  interference  with  the  formation  of  its  activating  prosecretin, 
or  its  conversion  into  secretin,  and  it  also  interferes  with  elimination  of  the 
enterokinase  which  activates  the  trypsinogen.  The  catarrh  may  spread 
into  the  common  bile-duct  and  into  the  pancreatic  duct;  in  the  latter 
instance  interfering  with  the  pancreatic  secretion,  and  also  partially  or 
completely  block  the  common  duct.  Obstruction  of  the  pancreatic  duct, 
from  the  pressure  of  tumors  or  from  calculi  in  the  common  duct,  or  similar 
conditions  affecting  the  pancreatic  ducts,  are  the  most  frequent  causes 
which  may  give  rise  to  a  more  or  less  complete  absence  of  the  pancreatic 
secretion  from  the  intestine.  Atrophy,  fatty  degeneration,  or  sclerosis 
of  the  pancreas  may  result.  With  interference  with  the  biliary  excretion, 
the  digestion  of  fat  would  be  markedly  diminished  and  the  pancreas  might 
be  involved. 

A  negative  sublimate  test  would  suggest  that  suppression  of  bile  was 
the  cause.     This  further  shows  the  necessity  of  care  in  diagnosis.     Anemia, 

972 


METHODS    OF   DIAGNOSIS   IN   PANCREATIC   DISEASE  973 

nervous  exhaustion,  fright,  grief,  mental  overwork,  worry  or  fa,tigue  from 
excessive  muscular  work,  or  sexual  excess,  Herter  gives  as  further  causes  of 
temporary  disturbance  of  the  pancreatic  secretion. 

With  chronic  duodenitis,  which  extends  into  the  ducts,  permanent 
damage  to  the  pancreas  may  result. 

Other  Conditions  Obscuring  the  Diagnosis. — With  tuberculosis  of  the 
intestines  and  peritoneum,  sprue,  and  amyloid  disease,  fat  absorption  is 
impaired,  and  these  facts  must  be  held  in  consideration.  Enterocolitis 
with  diarrhea,  the  use  of  purgatives,  and  excesses  in  diet  in  reference  to 
meat,  fats,,  and  carbohydrates,  must  also  be  considered.  The  gastric 
secretion  under  certain  conditions  influences  fat  digestion  when  the  fat  is 
contained  in  meat.  For  example,  collagen,  the  chief  constituent  of  con- 
nective tissue,  is  not  acted  on  by  the  pancreatic  juice  unless  previously 
boiled  with  water  or  unless  it  has  been  acted  on  by  an  acid.  Deficiency 
or  absence  of  hydrochloric  acid  in  the  stomach,  therefore,  may  cause  the 
appearance  of  an  abnormal  quantity  of  fat  in  the  feces.  On  the  other  hand, 
fats  and  soaps  stimulate  pancreatic  secretion  to  a  certain  degree,  and  this 
undoubtedly  accounts  for  the  fact  that  in  achylia  gastrica,  with  the 
absence  of  hydrochloric  acid,  nutrition  may  be  improved  by  the  adminis- 
tration of  fats,  such  as  cream,  butter,  milk,  etc. 

Therefore,  in  testing  the  digestive  capacity  of  the  pancreatic  juice, 
these  facts  may  be  taken  into  careful  consideration.  At  the  end  of  the 
chapter  the  author  recommetids  the  methods  which  he  considers  most  practical. 

There  are  two  methods  of  obtaining  the  pancreatic  ferments,  the 
direct  and  the  indirect. 

Direct  Methods. — Boas  has  obtained  the  duodenal  contents  by 
passing  the  stomach-tube  into  the  empty  stomach  and  massaging  near  the 
duodenal  region,  thus  forcing  the  juice  into  the  stomach;  while  Hemmeter 
and  Kuhn  have  passed  the  stomach-tube  directly  into  the  duodenum. 
These  procedures  are  uncertain. 

Einhorn  has  employed  the  duodenal  bucket  and  has  also  endeavored 
to  catheterize  the  duodenum.     They  are  impractical. 

There  are  two  methods  more  recently  introduced  by  which  it  is 
possible  to  secure  in  some  cases,  but  not  in  all,  the  duodenal  contents. 
There  are  two  instruments  reported  almost  synchronously,  the  duodenal 
tube  of  M.  Gross^  and  the  duodenal  pump  of  Einhorn. ^ 

The  Gross  Tube.^ — This  instrument  is  depicted  in  Fig.  410. 

It  consists  of  a  perforated  round  metal  ball  about  twice  the  size  of  a 
pea,  to  which  is  attached  a  thin  rubber  tube  0.2  cm.  in  diameter  and  125 
cm.  in  length,  marked  every  10  cm.  To  this  is  attached  a  glass  receptacle 
(bulb),  which  is  connected  by  a  length  of  tubing  with  a  mouth-piece, 
which  the  operator  can  use  to  aspirate,  or  to  which  an  aspirating  bulb  can 
be  attached. 

Gross  recommends  the  following  method:^ 

^'Test-meal. — The  patient  is  given  in  the  morning  a  tumbler  (250  c.c.) 
of  milk  and  water,  equal  parts.     This  mixture  does  not  cause  a  great  flow 

^N.  Y.  Med.  Jour.,  Jan.  8,  1910. 

^Med.  Rec,  Jan.  15,  1910. 

'Jour.  Amer.  Med.  Assoc,  April  23,  1910. 


974  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

of  hydrochloric  acid  and  contains  sufl5cient  fat  to  stimulate  the  pancreatic 
secretion.     Half  an  hour  later  introduce  the  duodenal  tube, 

"  Technic. — The  patient  swallows  the  ball  and  tube,  previously  wet  in 
water,  until  the  mark  45  cm.  reaches  the  lips.  Then  blow  lightly  through 
the  tube  into  the  stomach,  so  as  to  smooth  the  tube  out  and  that  it  will 
hang  freely  in  the  cavity.  The  patient  should  then  lie  down  and  slowly 
turn  over  on  the  right  side,  in  which  position,  after  a  few  minutes,  the  tube 
is  allowed  to  glide  down  through  the  mouth  without  swallowing,  following 
the  pull  of  the  ball,  until  the  mark  60  cm.  has  been  reached.  After 
five  or  ten  minutes  the  first  aspiration  may  be  made,  which  usually 
shows  contents  of  a  slightly  yellow  tint.  The  patient,  with  the  mouth  still 
partly  open,  should  not  make  any  swallowing  movements.  Gradually  the 
tube  will  be  drawn  down  to  the  65  or  70  cm.  mark. 

"A  second  aspiration  is  then  made,  and  usually  a  yellowish  fluid, 
free  from  casein,  will  be  aspirated,  giving  a  weakly  acid  or  acid  reaction. 


Fig.  410. — Gross  duodenal  tube. 

One  should  wait  a  little  longer  and,  after  several  aspirations,  the  yellow 
aqueous  contents  of  the  duodenum  will  usually  be  secured,  giving  a  neutral 
or  alkaline  reaction,  and  at  times  a  greenish-yellow  fluorescence." 

Precautions. — Occasionally  the  aspirated  fluid  remains  acid,  probably 
due  to  hyperchlorhydria,  and,  therefore,  neutralization  of  duodenal  con- 
tents may  occur  lower  down.  As  a  check,  give  a  cup  of  coffee  with  the 
tube  in  place.  Aspiration  should  be  performed,  and  if  the  fluid  is  still 
green,  the  contents  are  duodenal.  This  may  be  proved  by  withdrawing 
the  tube  a  short  distance  and  reaspirating,  when  the  coffee  will  appear. 
Gross  holds  that  unless  there  is  a  mechanical  obstacle  at  the  pylorus, 
it  is  usually  possible  to  pass  through  the  pylorus  with  the  tube  and  into 
the  duodenum  within  an  hour,^ 

Einhom's  Duodenal  Pump. — This  instrument,  similar  in  principle 
to  the  one  already  described,  is  readily  understood  from  the  illustration 
(Fig.  411). 

It  has  three  markings — 40  cm.  (cardia),  56  cm.  (the  pylorus),  and  70 
'  N.  Y.  Med.  Jour.,  July  9,   1910. 


METHODS    OF   DIAGNOSIS   IN   PANCREATIC   DISEASE 


975 


and  80  cm.  distance  from  the  capsule.  The  duodenal  contents  are 
aspirated  out  by  the  syringe,  the  cock  turned,  and  they  are  then  ejected 
into  a  vessel,  and  so  on. 

It  is  to  be  noted  that  Einhorn^  now  suggests  in  many  cases  that  the 
tube  be  inserted  on  retiring  at  night  and  be  left  thus  for  some  hours  before 
attempting  aspiration. 

The  patient  in  the  fasting  condition  drinks  a  cup  of  tea  with  sugar* 
and  without  milk,  and  then  about  one-half  to  three-quarters  of  an  hour 
later  the  capsule  and  tube  are  lubricated  in  water  and  gradually  swallowed, 
the  effort  being  aided  by  drinking  about  half  a  glass  of  water.  In  some 
cases  200  c.c.  milk,  bouillon  and  raw  eggs  are  given  one  to  two  hours  before 
aspiration.  To  be  sure  that  the  capsule  has  entered  the  stomach  and  is 
not  kinked,  one  can  aspirate  and  determine  the  presence  of  gastric  con- 
tents. A  syringeful  of  water  is  then  forced  through  the  tube  and  then 
one  of  air,  and  the  tube  is  then  shut  off  by  the  stop-cock  and  the  thread 
hitched  over  one  ear.  The  patient  should  not  close  the  lips  or  teeth  and 
should  read  for  about  an  hour. 


ttS^^i 


Fig.  411. — Einhorn's  duodenal  pump:  a,  Metal  capsule,  lower  half  provided  with 
numerous  holes,  the  upper  half  communicating  with  tube  b;  I,  II,  III,  marks  of  I  =  40, 
II  =  56,  III  =  70  cm.  from  capsule;  c,  rubber  band  with  silk  attached  to  end  of  tubing, 
which  can  be  placed  over  the  ear  of  the  patient;  d,  three-way  stop-cock;  e,  collapsible 
connecting  tube;/,  aspirating  syringe. 

When  the  tube  reaches  the  mark  70  cm.  at  the  lips,  aspiration  is 
attempted.  If  the  capsule  is  in  the  duodenum,  on  aspirating  one  generally 
obtains  a  golden-yellow  watery  liquid  of  alkaline  reaction,  somewhat  viscid 
in  consistency, 

Einhorn^  now  recommends,  as  soon  as  the  flow  commences,  that  the 
piston  of  the  syringe  be  removed  and  the  barrel  be  kept  low,  so  as  to  siphon 
out  the  fluid. 

At  times  one  does  not  obtain  the  duodenal  contents,  as  the  tube  may 
coil  in  the  stomach.  If  acid  gastric  contents  are  obtained,  withdraw  the 
tube  to  the  56-cm.  mark,  wash  it  out  with  water,  and  then  blow  in  air,  and 
in  half  an  hour  try  again.  When  the  tube  lies  in  the  stomach,  it  does  not 
collapse  on  aspiration;  when  it  lies  in  the  duodenum,  it  collapses  and 
aspiration  is  slower. 

As  a  further  test,  one  can  give  the  patient  a  little  milk  with  the  tube 
in  place,  and  if  the  capsule  lies  in  the  duodenum  no  milk  will  appear. 

,    *Amer.  Jour.  Med.  Sci.,  October,  1914,  No.  4,  vol.  cxlviii. 
2  Jour.  Amer.  Med.  Assoc,  July  2,  1910,  vol.  fv,  pp.  6-8. 


976  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Palefoki  has  also  devised  a  duodenal  tube,  an  improvement  on  those 
described.     There  are  others  also  reported. 

The  writer  finds  these  methods  of  obtaining  the  duodenal  contents 
are  by  no  means  always  successful.  I  have  succeeded  in  entering  the 
duodenum  in  a  little  over  an  hour's  time  in  a  patient  with  normal  gastric 
motility,  but  on  other  occasions  have  been  obliged  to  wait  a  number  of 
hours. 

Patients  who  have  an  irritable  pharynx  and  esophagus  will  not  retain  the 
instrument  for  the  time  necessary  to  secure  the  duodenal  contents.  In 
cases  where  there  is  pyloric  stenosis,  even  of  no  marked  degree,  in  the 
atonic  dilatation  of  the  stomach,  and  often  in  atony  of  the  stomach,  the 
procedure  may  prove  a  failure.  With  normal  conditions  of  the  stomach 
it  may  sometimes  be  unsuccessful,  or  only  a  drop  or  two  or  no  contents  be 
extracted,  even  when  the  tube  is  apparently  in  the  duodenum. 

Moreover,  the  pancreatic  ferments  are  active,  even  in  very  small 
quantities,  and  as  long  as  there  is  any  pancreatic  tissue  functionating  and 
the  possibility  of  its  escape  into  duodenum,  one  would  expect  to  secure 
the  reactions  due  to  their  presence. 

This  last  view  is  referred  to  by  Deaver.^ 

The  mere  presence  of  the  ferments,  therefore,  is  not  conclusive  that 
there  is  no  pancreatitis.  Einhorn  states,  however,  that  if  one  of  the  fer- 
ments is  persistently  absent  it  usually^  indicates  chronic  pancreatitis. 
He  does  not  claim  it  invariably  does  so. 

The  Schmidt-Strasshurger  diet  might  show  marked  deficiency  in  pan- 
creatic function  for  an  average  diet,  while  the  direct  test  itidicated  the  pancreatic 
ferments  to  be  present. 

The  writer  believes  the  tests  of  the  intestinal  functions  should  he  used 
in  every  case. 

EXAMINATION  OF  THE  DUODENAL  CONTENTS 

Bile-pigment. — Add  i  c.c.  of  fuming  nitric  acid  to  i  c.c.  of  the  duo- 
denal contents  in  a  test-tube  and  note  if  Gmelin's  reaction  occurs.  With 
sufficient  bile,  the  juice  turns  green. 

The  following  simple  tests  are  suggested  by  Einhorn  for  the  ferments:' 

Steapsin. — Take  i  drop  of  neutral  milk,  2  drops  of  water,  and  2  to 
3  drops  of  the  duodenal  contents,  which  should  be  neutralized  if  the  reac- 
tion is  acid,  and  add  a  small  piece  of  blue  litmus-agar.  Place  this  in  a 
small  test-tube  and  keep  it  at  blood  temperature.  If  steapsin  is  present 
the  agar  piece  turns  red  in  twenty  to  thirty  minutes,  owing  to  the  develop- 
ment of  fatty  acids.  The  writer  finds  an  excellent  incubator  is  a  Thermos 
bottle  containing  water  at  99°  to  ioo°F.,  in  which  the  corked  test-tube  can 
be  placed. 

Nile-blue  sulphate  has  been  advocated  by  Lohrisch  as  a  specific  stain 

for  fat  in  the  examination  of  feces  and  gastric  contents.     Neutral  fats 

assume  a  red  color,  while  fatty  acids  become  blue.     Employ  olive  oil. 

25  gm. 

^  Ibid.,  April  15,  191 1. 

*  N.  Y.  Med.  Jour.,  Oct.  18,  1913.  * 

'  Am.  Jour.  Med.  Sci.,  October,  1914,  No.  4. 


METHODS    OF    DIAGNOSIS    IN    PANCREATIC    DISEASE  977 

Agar-agar,  2  gm. 

Sol.  nile-blue  sulphate  (i  :20Oo),  add  100  gm.  The  olive  oil  nile-blue 
tube  which  has  a  violet  tint  becomes  blue  when  steapsin  is  present.  It 
otherwise  remains  unchanged  or  becomes  slightly  purple.  The  amount 
of  agar  column  in  millimeters  turning  blue  represents  the  approximate 
quantity  of  the  fat-splitting  ferment.  These  tubes  can  be  prepared  in 
any  laboratory  or  can  be  secured  from  Eimer  and  Amend.  They  are 
recommended  by  Einhorn. 

He  suggests^  specially  prepared  tubes  of  agar  powder  but  they  possess 
no  advantages. 

Trypsin. — If  the  fluid  (duodenal)  is  acid,  neutralize  it  and  place  in  it 
a  small  piece  of  white  of  a  hard-boiled  egg.  Keep  it  a  few  hours  at 
blood  temperature.     If  trypsin  is  present,  the  albumin  disappears. 

Amylopsin. — To  test  for  diastase,  use  a  boiled  starch  solution  or  starch- 
paper.  Either  mix  the  duodenal  contents  with  equal  parts  of  starch 
solution  or  insert  in  it  a  strip  of  starch  test-paper,  and  leave  it  at  blood 
temperature.  In  half  an  hour  to  an  hour  add  a  weak  iodin  solution,  and 
if  dextrin  is  present,  the  starch  solution  or  paper  turns  blue;  if  erythro- 
dextrin  is  present,  we  have  a  red  color. 

One  must  always  note  with  litmus-paper  the  reaction  of  the  duodenal 
contents.  It  is  usually  alkaline,  though  occasionally  HCl  is  present, 
giving  an  acid  reaction. 

Gross-  recommends  the  following,  though  more  complicated  tests  are 
suggested: 

Amylopsin. — A  quantity  of  a  i  per  cent,  aqueous  solution  of  Kahl- 
baum's  soluble  starch  is  heated  in  the  incubator  to  55°C.;  also  a  number 
of  empty  test-tubes  are  heated  up;  5  c.c.  of  the  heated  starch  is  put  in  a 
hot  tube,  4  drops  of  duodenal  juice  are  added,  and  the  tube  shaken  for 
about  a  minute;  >^  c.c.  of  a  250th  normal  iodin  solution  is  then  added. 

This  normal  iodin  solution  consists  of  an  aqueous  solution  of  equal  parts 
of  iodin,  iodid  of  soda,  potassium  iodid,  and  ammonium  iodid,  i  :  250. 

If  no  amylopsin  is  present,  the  solution  becomes  blue;  or  green  if  bile 
is  present;  if  traces  of  amylopsin  are  present,  it  turns  blue  violet;  if  marked 
traces,  then  red  violet;  if  the  quantity  is  normal,  then  pale  pink;  and  if  an 
excess,  then  it  is  colorless. 

If  to  this  solution  Fehling's  alkaUne  solution  is  added,  it  will  become 
colorless.  On  the  addition  of  Fehling's  copper  solution  on  boiling,  the 
sugar  reaction  occurs,  if  such  is  present. 

Steapsin. — Melt  some  fresh  butter  and  abstract  the  clean,  pure  fat 
mixture  with  a  little  o.i  per  cent,  aqueous  carbonate  of  potash  and 
phenolphthalein  solution,  and  then  shake  and  titrate  with  liquor  sodae 
until  a  distinct  red  coloration  remains.  This  solution  is  then  heated  in  the 
incubator  to  55°C.  Then  5  c.c.  of  this  is  shaken  with  5  drops  of  intestinal 
juice  in  a  heated  test-tube. 

If  there  are  normal  quantities  of  steapsin,  the  red  color  will  disappear 
in  from  two  to  five  minutes.  The  quantity  of  active  steapsin  can  be 
estimated  from  the  rapidity  of  this  discoloration. 

'  Med.  Rec,  Oct.  12,  191 2. 

-Med.  Rec,  May  21,  1910;  Ibid.,  Nov.  12,  igio. 
62 


978  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Trypsin. — Mix  a  solution  of  0.07  per  cent,  copper  sulphate  and  o.i 
per  cent,  sodium  carbonate  with  a  few  drops  of  Fehling's  alkaline  solution 
and  a  5  per  thousand  of  casein.  Heat  this  in  an  incubator  to  5 5°C.  Shake 
up  5  c.c.  of  this  with  5  drops  of  the  duodenal  contents.  The  color  is  at 
first  blue  or  green  if  bile  is  present.  Depending  on  the  quantity  of  trypsin, 
it  will  become  more  or  less  red  violet,  and  after  a  few  minutes,  pink. 

Indirect  Methods  of  Obtaining  the  Ferments. — Pawlow*  discovered 
that  if  he  administered  oil,  to  dogs  having  a  gastric  fistula,  within  one  or 
two  hours  he  was  able  to  obtain  an  emulsion  containing  bile  and  pancreatic 
juice  due  to  the  regurgitation  of  the  duodenal  contents  into  the  stomach. 

Boldyreff2  used  a  combination  of  fatty  acid  in  oil  and  secured  a 
regurgitated  fluid  containing  trypsin. 

Levinsky^  advises  giving  half  a  teaspoon  of  magnesia  usta  twenty 
minutes  before  the  oil,  and  a  second  dose  twenty  minutes  after,  to 
neutralize  the  acidity  of  the  stomach  contents.  This  is  the  method  that 
is  usually  employed. 

The  technic  is  as  follows: 

First  determine  the  acidity  of  the  gastric  juice  and  if  free  hydro- 
chloric acid  is  present;  then  on  an  empty  stomach  one-half  teaspoon  of 
magnesia  usta  is  given  in  water,  and  this  is  followed  in  twenty  minutes 
to  half  an  hour  by  200  c.c.  of  olive  oil,  and  twenty  minutes  later  by 
another  half  teaspoon  of  magnesia  usta.  Three-quarters  of  an  hour 
later  the  stomach  should  be  aspirated,  and  the  fluid,  which  is  often  greenish 
yellow,  should  be  placed  in  a  separating  funnel.  The  oil  rises  to  the 
surface.  The  lower  part  of  the  fluid  is  tested  for  trypsin  and  the  other 
ferments. 

Abderhalden  and  Schittenhelm,^  in  order  to  determine  the  presence  of 
trypsin,  advise  the  use  of  the  polypeptid,  glycyltyrosin.  This  optically 
active  peptid  cannot  be  split  by  pepsin,  but  is  acted  on  by  trypsin,  the 
tyrosin  crystallizing  out.  They  have  also  employed  a  solution  of  silk 
peptone,  which  contains  40  per  cent,  tyrosin,  and  observe  the  rotation 
of  light  by  the  polariscope. 

The  author  believes  the  simpler  methods  to  determine  the  presence 
of  the  ferments  to  be  preferable  for  the  general  practitioner. 

Securing  the  Ferments  from  the  Feces. — The  O.  Gross  ^  method  is 
usually  employed.  He  recommends  a  high  protein  diet  for  two  to  three 
days  previous  to  the  test,  and  a  mild  saline  purgative  the  morning  of  the 
day  when  the  test  is  to  be  made,  so  as  to  hurry  the  stool  through  the 
intestinal  tract,  that  there  may  be  less  loss  of  ferment  by  bacterial  action. 
The  stool  should  be  examined  as  soon  as  possible. 

A  solution  of  }i  gram  of  casein  (Grubler)  is  dissolved  in  i  liter  of 
sodium  carbonate  solution  (i :  1000).  A  portion  of  the  stool  is  rubbed 
up  with  three  times  the  amount  of  soda  solution  and  filtered;  10  c.c. 
of  this  filtrate  are  placed  in  a  small  flask  with  100  c.c.  of  the  casein  soda 
solution,  and  a  little  chloroform  is  added.     The  mixture  is  then  put 

^Arbeit  der  Verdauungsdriisen,  Wiesbaden,  1898,  pp.  159-161. 

2  Report  of  International  Physiolog.  Congress,  Brussels,  1904. 

3  Deutsche  Medezin  Wochenschr.,  1907,  p.  403. 
*Zeitschr.  fiir  Physiolog.  Chemie.,  Ixi,  p.  421,  1909. 
^Deut.  Med.  Woch.,  1909,  Nr.  16. 


METHODS    OF   DIAGNOSIS   IN   PANCREATIC   DISEASE  979 

in  the  incubator  at  38°C.,  and  after  four  and  eight  hours  respectively  is 
tested  by  taking  out  10  c.c.  and  adding  to  it  with  care,  drop  by  drop,  a 
1  per  cent,  acetic  acid  solution.  If  the  solution  is  clear,  the  casein  has 
been  digested ;  if  it  becomes  cloudy,  the  flask  is  put  back  into  the  incubator 
and  tested  again  after  twelve,  fourteen,  and  twenty-four  hours.  At 
the  end  of  this  time,  if  no  digestion  has  taken  place  (if  the  solution  is  still 
cloudy),  trypsin  is  absent  or  very  markedly  diminished. 

Frank  recommends  the  use  of  the  Berkfeldt  filter  under  pressure 
before  this  test,  in  order  to  insure  a  clear  filtrate,  but  it  is  difficult  to  clean, 
and  some  of  the  ferment  is  liable  to  be  lost. 

When  we  estimate  the  value  of  the  casein  method  we  must  remember 
that  the  erepsin  in  the  intestinal  juice  and  bacterial  action  have  some 
digestive  effect  on  this  product.  Attempts  have  been  made  by  Schitten- 
helm^  and  Frank  to  isolate  erepsin. 

Miiller's  Serum  Plate  Method  for  Trypsin. — This  method"  is  as 
follows:  A  glycerin  injection  is  first  given  to  empty  the  lower  bowel. 
The  patient  is  then  given  a  test-meal  of  150  grams  of  meat  and  150 
grams  of  potato  gruel,  and  several  hours  later  a  strong  laxative  is  given. 
If  the  stool  which  results  is  thick,  rub  it  up  with  glycerin  water  (10  in 
1000).  If  it  is  acid  or  neutral,  render  it  alkaline  with  soda.  Small 
drops  of  the  feces  are  then  placed  on  the  surface  of  a  serum  plate.  This 
last  consists  of  a  Petri  dish  covered  with  a  fairly  thick,  layer  of  coagulated 
blood-serum.     This  is  then  placed  in  an  incubator  at  50°  to  6o°C. 

If  an  active  proteolytic  ferment  is  present,  small  depressions  soon 
appear  in  the  serum  due  to  digestion  by  the  enzyme.  In  the  absence 
of  the  ferment  no  depressions  occur. 

The  ferment  contained  in  leukocytes  will  produce  pitting  of  the  plate, 
so  that  if  pus  or  blood  are  present  in  the  stool  the  specimen  should  be 
discarded. 

If  large  quantities  of  fat  are  present,  it  may  interfere  with  the  test. 
The  fat  should  be  first  removed  by  shaking  out  with  ether. 

Schmidt's  Nuclei  Test. — Adolf  Schmidt^  introduced  a  test  which 
depends  on  the  power  of  the  pancreatic  juice  to  dissolve  the  nuclei  con- 
tained in  meat.  Small  pieces  of  meat  are  hardened  in  absolute  alcohol 
and  enclosed  in  small  gauze  bags.  These  are  soaked  in  water  for  some 
hours  and  then  swallowed.  The  stool  is  searched  for  the  bags,  and  the 
contents  are  frozen,  cut,  and  then  stained  with  hematoxin,  and  examined 
for  the  presence  of  nuclei.  If  they  are  not  found,  one  presumes  the 
pancreatic  juice  has  digested  them.  If  they  are  present,  it  is  assumed  that 
the  juice  is  absent.  There  is  a  question  as  to  how  much  the  digestion  of 
the  nuclei  is  affected  by  erepsin,  and  Klieneberger^  states  that  nuclei  have 
been  found  intact  when  the  pancreas  was  not  involved.  Einhorn  disputes 
the  test.  Moreover,  in  cases  of  diarrhea  the  bags  may  pass  through  so 
quicky  that  the  pancreatic  juice  has  no  chance  to  act,  and  in  cases  of 
marked  intestinal  putrefaction  the  nuclei  may  be  destroyed. 

^  Zentralblatt  der  Gesamt.  Physiol,  und  Pathol,  des  Stoffwechsels,  1909,  Nr.  23. 
^  Medizin.  Klinik,  1909,  Nr.  16,  p.  573. 
^  Deut.  Med.  Woch.,  1899,  Nr.  49,  p.  811. 
*  Medizenische  Klinik,  1910,  p.  89. 


980  DISEASES   OF    THE    STOMACH   AND   INTESTINES 

Sahli's  Test.^ — He  employs  a  gelatin  capsule  hardened  with  formol 
and  containing  0.5  gm.  of  iodoform,  or  one  with  0.25  gm.  of  salol.  The 
capsule  is  given  with  the  Ewald  test-meal,  and  normally  iodin  can  be 
recovered  in  the  saliva,  or  salicyluric  acid  (from  the  salol)  in  the  urine 
in  four  to  six  hours. 

A  strip  of  starch-paper  moistened  with  the  saliva  and  touched  with 
fuming  nitric  acid  gives  a  violet  or  blue  color  for  iodin — from  the  iodoform 
capsule.  The  urine  tested  with  neutral  ferric  chlorid  solution  gives  a 
violet  color  when  the  salol  test  is  used.  Sahli  prefers  the  salol  test. 
Two  or  three  of  the  salol  capsules  are  given.  One  should  be  sure  of  the 
condition  of  the  motor  function  of  the  stomach,  and  this  should  be  first 
investigated.  Absorption  from  the  intestines  would  be  interfered  with 
by  a  catarrhal  condition,  and  in  case  of  diarrhea  the  capsule  may  pass 
through  unchanged.     All  these  conditions  must  be  considered. 

Sodium  Fluorid  Fibrin  Test. — This  method,  devised  by  Huber  and 
Arthur,^  consists  in  soaking  strips  of  fibrin  in  a  2  per  cent,  solution  of 
sodium  fluorid  for  twenty-four  hours  at  40°C.  The  material  to  be 
tested  is  then  diluted  with  an  equal  amount  of  the  sodium  fluorid  solu- 
tion, and  the  whole  is  digested  for  a  considerable  time  at  4o°C.  If  trypsin 
is  present,  crystals  of  tyrosin  appear. 

THE  FATS  IN  THE  FECES 

Normally,  little  more  than  5  to  10  per  cent,  of  fat  escapes  absorp- 
tion. Impaired  assimilation  of  fats  and  proteins  is  more  readily  recog- 
nized than  alterations  affecting  the  digestion  of  the  carbohydrates. 

Experiments  on  animals  have  demonstrated  that  extirpation — 
complete  or  partial — or  destruction  of  the  pancreas  is  attended  by  a 
defective  absorption  of  fat,  except  of  the  emulsified  fat  of  milk,  in  which 
case  a  greater  proportion  was  assimilated.  Similar  disturbances  of 
digestion  occur  in  human  cases,  where  the  pancreas  has  been  partially 
destroyed  by  chronic  inflammation,  by  cysts,  and  by  new  growths. 

Occlusion  of  the  duct  caused  by  calculi  or  by  tumor,  followed  by 
degenerative  changes  in  the  gland,  may  produce  the  same  effect. 

Opie^  shows  that  even  when  the  dud  of  Wirsung  is  obstructed  the  pan- 
creatic juice  may  reach  the  intestine  through  the  duct  of  Santorini  in  about 
three-fourths  of  all  individuals,  and  that  often  digestion  proceeds  with 
no  manifest  impairment. 

In  estimating  whether  a  true  fatty  stool  (steatorrhea)  is  present, 
one  must  exclude  the  acholic  stool  due  to  the  absence  of  bile-pigment. 
The  acholic  stool  is  grayish  white,  ash  gray,  or  of  clay  color,  due  to  the 
absence  of  bile-pigment.  Dilute  fecal  matter  added  to  a  strong  solu- 
tion of  bichlorid  of  mercury  is  colored  red  when  unchanged  bile-pigment 
is  present.  A  negative  sublimate  test  suggests  the  suppression  of  bile  through 
occlusion  of  the  bile-duct.  There  is  considerable  fat  in  the  acholic  stool, 
seen  microscopically  as  needle-shaped  crystals  or  in  sheaves  of  crystals, 
or,  at  times,  in  fat-droplets.     Owing  to  the  absence  of  bile  from  the  in- 

*  Lehrbuch  der  Klinischen  Untesruchungs  Methoden,  1909,  p.  570. 
2  Arch,  de  Physiologic,  1898,  p.  622. 
'  Disease  of  the  Pancreas. 


METHODS    OF   DIAGNOSIS    IN   PANCREATIC    DISEASE  98 1 

testinal  tract,  the  emulsifying  power  of  the  pancreatic  juice  is  diminished 
and  excess  of  fat  appears. 

Moreover,  an  abnormal  quantity  of  fat  may  appear  in  the  stools  of 
healthy  individuals  after  the  ingestion  of  great  quantities  of  fat.  The 
stool  may  also  be  devoid  of  color  or  grayish  white  where  there  is  no 
jaundice  and  no  occlusion  of  the  bile-ducts,  with  stercobilin  present  and 
large  quantities  of  fat,  in  conditions  where  the  absorption  of  fat  is  impaired, 
such  as  with  tuberculosis  of  the  intestines  and  tuberculosis  of  the  mesen- 
teric glands.  Fat  may  also  appear  in  excess  in  the  stools  in  extensive 
catarrh  of  the  intestines  and  in  conditions  accompanied  by  active  peristal- 
sis. Only  in  the  absence  of  the  above  conditions  is  the  presence  of  excessive 
fat  in  the  stools  an  aid  to  the  diagnosis  of  pancreatic  disease. 

Steatorrhea. — This  term  is  strictly  applied  to  those  cases  in  which 
the  fat  is  discharged  in  the  feces  as  an  oily  yellow  fluid,  or  in  isolated 
masses,  visible  to  the  naked  eye. 

Opie  states  there  are  some  cases  of  pancreatic  disease  in  which  the 
feces  are  clay  colored  or  grayish  white,  frequently  with  a  metallic  or 
asbestos-like  appearance,  and  that  the  increased  quantity  of  fat  can  be 
demonstrated  only  by  microscopic  or  chemic  examination.  These 
stools  contain  fatty  acids,  neutral  fats,  and  soaps. 

Steatorrhea  may  follow  the  loss  of  pancreatic  secretion,  and  Fitz 
demonstrates  its  diagnostic  value  when  it  is  present.  Up  to  1903  he 
collected  only  29  cases  in  which  there  were  fatty  stools  in  patients  in 
whom  there  was  conclusive  evidence  of  pancreatic  disease. 

Theodor  Brugsch^  states  that  in  pancreatic  disease,  without  jaundice, 
the  average  loss  of  fat  is  64  per  cent.;  with  mild  jaundice  associated, 
the  loss  is  72  per  cent.  While  in  cases  in  which  the  bile  is  completely 
shut  off,  the  loss  of  fat  is  87  per  cent. 

A  case  of  carcinoma  has  been  reported  by  Robson  in  which  93  per 
cent,  of  the  dried  feces  was  fat,  and  with  chronic  pancreatitis  the  fat  per 
cent,  has  been  as  high  as  80  to  82. 

With  pancreatic  disease,  observers  report  a  great  reduction  in  split  fat. 

Fr.  Miiller^  states  that  in  normal  feces  from  20  to  30  per  cent,  of 
the  fat  is  neutral  fat,  while  from  70  to  80  per  cent,  is  split  fat,  in  the 
form  of  fatty  acids  and  soaps.  With  pancreatic  disease,  the  feces,  on 
the  other  hand,  may  contain  a  diminished  proportion  of  split  fat,  although 
the  total  fat  may  not  be  increased. 

Fitz  has  collected  seven  cases  of  pancreatic  disease  without  jaundice  in 
which  there  was  no  steatorrhea.  The  proportion  of  neutral  fat  was  normal 
or  less  than  normal  in  only  one  case,  while  in  the  rest  it  averaged  56.84 
per  cent. 

One  must  remember  that  cases  of  undoubted  pancreatic  disease 
occur  in  which  there  is  no  marked  loss  of  fat,  so  that  the  absence  of  steatorrhea 
does  not  exclude  pancreatic  disease. 

The  author  has  already  referred  to  the  fact  that  though  disease  of  the 
pancreas  is  present,  that  even  with  closure  of  the  duct  of  Wirsung,  a 

^Lehrbuch  Klinischer  Untersuchungs  Methoden,  1909,  p.  371. 
*  Zeit.  fur  Klin.  Med.,  xii,  p.  51,  1887. 


982  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

patent  duct  of  Santorini  may  allow  the  escape  of  pancreatic  juice  into 
the  intestines. 

Early  in  the  stages  of  the  disease,  little  change  will  occur  in  the  fat 
content  of  the  stool,  and  if  little  fat  be  ingested  by  the  patient  or  milk 
be  taken,  in  which  form  the  emulsified  fat  is  readily  absorbed,  no  noticeable 
difiFerence  would  occur. 

Some  have  also  offered  the  theory  that  there  is  an  increase  in  the 
activity  of  the  stomach  lipase. 

One  must  consider  all  these  possibilities,  and  hence  early  diagnosis 
is  often  difficidt  and  frequently  impossible. 

In  order  to  estimate  the  amount  of  fat  in  the  stools,  it  is  necessary 
to  employ  a  test-meal  containing  known  amounts  of  fat.  One  can  employ 
the  Schmidt-Strassburger  test-diet  or  Steele's  modification,  as  under 
Testing  the  Intestinal  Functions,  or  that  recommended  by  Brugsch, 
which  consists  of  2  liters  of  milk,  150  grams  of  white  bread,  and  50  to 
100  grams  of  butter.  With  this  meal  a  capsule  of  carmine  is  given  to 
identify  the  resulting  stool.  It  would  seem  best  to  divide  this  into  two  or 
even  three  meals. 

The  characteristics  of  a  fatty  stool  have  already  been  described. 

Robson  and  Cammidge  describe  a  special  method  of  their  own  for 
determining  the  fat  in  the  feces.     Their  technic  is  as  follows: 


;,,,■■■,-■,■•..■■-■■-■■•  h-C 


Fig.  412. — Schmidt-Stokes  milk-tube  (Robson  and  Cammidge). 

"They  employ  two  dry,  clean  Schmidt-Stokes  milk  tubes,  which  they 
label  'A'  and  'B'  (Fig.  412).  Each  is  provided  with  a.  10  c.c.  mark. 
About  >^  gram  of  finely  powdered  feces,  which  have  been  dried  on  a  water- 
bath,  is  introduced  into  the  lower  bulb  of  each  tube. 

"The  residue,  on  the  watch-glass  used  for  weighing  and  on  the  sides 
of  the  short  funnel  through  which  the  powder  is  poured  into  the  tubes, 
is  washed  down  by  a  fine  jet  from  a  wash  bottle,  which  for  A  tube  contains 
hydrochloric  acid  (i  :3),  and  for  B  tube,  plain  water. 

"The  sides  of  the  tubes  are  also  washed  until  all  is  collected  in  the  lower 
bulbs,  and  the  tubes  are  each  filled  with  solution  to  the  10  c.c.  mark. 

"Tube  A  is  then  heated  in  boiling  water  for  twenty  minutes,  rotating 
it  occasionally  so  as  to  thoroughly  mix  its  contents.  After  it  is  cooled, 
both  tubes  are  filled  to  the  50  c.c.  mark  with  ether.  They  are  then 
tightly  corked  and  inverted  about  forty  times,  so  that  all  the  material 
runs  from  bulb  to  bulb  at  each  turn.  Each  tube  is  then  rotated  between 
the  hands  and  then  allowed  to  stand  for  half  an  hour  or  more,  so  that  the 
solid  residue  may  collect  in  the  lower  bulbs.  The  upper  layers  of  ether  in 
the  tubes  should  be  clear  and  free  from  solid  particles. 

"Draw  off  from  each  tube  20  c.c.  of  the  ethereal  extract  with  a 
pipet,  and  place  each  in  a  CO2  flask  of  known  weight,  also  noting  the 
amount  of  ether  left  in  the  two  tubes. 

"The  ether  in  each  flask  is  then  evaporated,  the  residue  dried  on  a 
water-bath,  and  the  flasks  are  again  weighed. 


METHODS   OF  DIAGNOSIS. IN   PANCREATIC   DISEASE  983 

"From  the  amount  of  extract  yielded  by  the  20  c.c.  of  ether,  and 
the  quantity  of  ether  left  in  the  tubes,  the  total  amount  yielded  by 
the  weight  of  dried  feces  used  may  be  calculated,  and  from  this  the 
percentage  in  the  stool  may  be  determined. 

"The  result  from  tube  A  gives  the  total  fat  in  the  feces,  i.e.,  neutral 
fats,  free  fatty  acids,  and  combined  fatty  acids  or  soaps;  since  the  latter 
are  decomposed  by  boiling  with  hydrochloric  acid  and  are  thus  rendered 
soluble. 

"The  residue  from  B  tube  represents  the  neutral  fats  a.nd  fatty  acids, 
as  the  soaps  are  undissolved  by  the  ether. 

"The  difference  between  the  two  gives  the  proportion  of  saponified 
fat.  Other  substances  in  the  feces  are  negligible.  For  convenience 
we  may  say  tube  A  gives  the  total  fat,  tube  B,  the  'neutral  fat,'  and  the 
difference  between  the  two,  the  'fatty  acid.' 

"Robson  recommends  testing  the  solid  residue  of  tube  B  for  ster- 
cobilin.  The  contents  of  B  are  filtered  off,  then  extracted  with  acid 
alcohol,  the  extract  neutralized  with  ammonia,  and  then  mixed  with  a 
quantity  of  10  per  cent,  zinc  acetate  in  alcohol.  The  precipitate  is  re- 
moved by  filtration  and  the  clear  filtrate  examined  through  a  lens  against 
a  black  background. 

"A  green  fluorescence  indicates  the  presence  of  stercobilin.  The 
intensity  of  the  color  varies  with  the  amount  of  the  pigment." 

The  total  absence  of  pancreatic  juice  and  bile,  however,  does  not 
always  put  an  end  to  the  fat-splitting  process  in  the  intestines;  by  the 
organisms  of  the  colon  group  fats  are  converted  into  glycerin  and  fatty 
acids  in  the  lower  part  of  the  small  intestine.  Absorption  will  be  dimin- 
ished, and  they  will  be  largely  excreted  in  the  feces.  The  appearance 
of  a  larger  proportion  of  saponified  fat  in  the  stools  than  would  be  expected 
in  some  cases  of  severe  pancreatic  disease,  is  probably  explained  in  this  way. 

The  author  has  already  referred  to  the  influence  of  simple  biliary 
obstruction,  defective  gastric  digestion,  excess  of  fat  in  the  diet,  disease 
of  the  intestinal  mucosa,  intestinal  tuberculosis,  tubercular  peritonitis, 
etc.,  which  would  all  influence  the  excretion  of  fat,  and  which  must  be 
excluded. 

Color  of  the  Stool  in  Steatorrhea. — The  white  appearance  of  the 
feces  due  to  diminution  or  exclusion  of  the  pancreatic  secretion  from 
the  intestines  can  be  attributed  chiefly  to  the  presence  of  excess  of  fat, 
especially  the  crystalline  fatty  acids.  It  is  believed  to  be  partly  due  to 
the  reducing  action  of  bacteria  growing  anerobically  in  an  acid  medium. 
Miiller  has  attributed  it  chiefly  to  the  absence  of  bile  through  the  blocking 
of  the  biliary  passage.  When  such  occurs  it  would  be  a  contributory 
factor,  but  it  can  be  demonstrated  that  bile  is  present  in  some  cases. 

THE  USE  OF  PANCREATIC  ENZYMES  AS  AN  AID  TO  DIAGNOSIS; 
PANCREATIC  INFANTILISM 

In  the  case  of  animals  in  whom  the  pancreas  has  been  removed, 
it  was  found  possible  to  increase  the  assimilation  of  fats  and  proteins 
by  the  administration  of  fresh  pancreas. 


984 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


Pancreatic  Infantilism. — BramwelP  describes  a  case  in  which  he 
beUeved  that  retarded  development  was  due  to  deficient  pancreatic  action. 
The  patient,  eighteen  years  of  age,  had  suffered  from  diarrhea  for  nine 
years,  and  there  was  arrested  development  after  the  age  of  eleven.  There 
were  disappearance  of  diarrhea  and  a  rapid  increase  in  weight  after  the 
administration  of  a  glycerin  extract  of  the  pancreas. 

Thompson^  and  RentouP  record  similar  instances,  though  Herter 
is  inclined  to  attribute  them  to  chronic  intestinal  putrefaction.  In 
this  connection  the  author  refers  his  reader  to  a  case  of  infantilism  with 
hypochlorhydria  and  chronic  intestinal  putrefaction  under  the  section 


Fig.  413. — Microscopic  characters  of  the  residues  met  with  in  the  stools  in  cases 
of  pancreatic  disease  and  biliary  obstruction:  a,  Striated  muscle-fibres;  b,  fat  globules; 
c,  free  fatty  acid  crystals;  d,  combined  fatty  acid  (soap)  crystals  (Robson  and  Cam- 
midge). 

"Hypochlorhydria."  The  treatment  for  the  condition  is  fully  described 
in  that  article. 

Robson  and  Cammidge  report  a  case  of  chronic  pancreatitis  demon- 
strated by  operation,  in  which  after  the  administration  of  "pancreon" 
the  neutral  fat  was  diminished  over  40  per  cent.,  and  the  fatty  acid  in- 
creased II  per  cent,  in  the  stools. 

The  use  of  pancreatic  extract  might,  therefore,  be  of  some  aid  to  diagnosis, 
especially  if  improvement  hi  the  stools,  with  diminished  fat  excretion,  restdted 
therefrom.    This  would  suggest  at  once  pancreatic  deficiency. 

Azotorrhea. — The  presence  of  unaltered  muscle-fibers  in  the  feces  is 
significant  of  disturbance  of  protein  digestion. 

Fitz"*  found  only  eight  cases  in  which  this  occurred  in  pancreatic  disease. 

*  Scottish  Med.  and  Surg.  Jour.,  1904,  xiv,  321. 

*  Robson  and  Cammidge. 

'  Brit.  Med.  Jour.,  1904,  ii,  loii. 

*  Trans.  Cong,  of  .\mer.  Phys.  and  Surg.,  1903,  vi,  36. 


METHODS    OF   DIAGNOSIS    IN    PANCREATIC   DISEASE  985 

Examination  should  be  made  under  the  microscope,  where  the  muscle- 
fiber  is  readily  recognized  (Fig.  413). 

Rarely,  undigested  muscle  can  be  detected  in  the  stool  with  the  naked 
eye.  In  forming  proper  judgment,  one  must  exclude  an  excessive  meat 
diet,  and  also  cases  in  which  for  any  reason  there  is  increased  peristalsis, 
as  in  intestinal  catarrh,  or  intestinal  putrefaction  with  secondary  diarrhea. 

In  such  event,  the  contents  are  hurried  through  the  intestines  before 
they  can  be  digested.  The  stomach,  moreover,  digests  the  connective 
tissue  of  meat,  and  deficient  gastric  digestion  would  lead  to  imperfect 
digestion  of  muscle,  since  the  meat  fibers,  under  such  conditions  entering 
the  intestines,  bound  together  by  connective  tissue,  would  be  attacked 
less  rapidly  by  the  pancreatic  juice.  Undigested  meat  fibers  would  thus 
readily  pass  through  the  intestinal  canal. 

Nitrogen  in  the  Feces. — Under  normal  conditions  only  5  to  6  per 
cent,  of  nitrogen  is  lost  in  the  feces.  In  a  case  of  pancreatic  diabetes, 
Hirschfeld^  recovered  32  per  cent,  of  the  nitrogen  ingested  with  the  food. 
In  pancreatic  disease  without  jaundice,^  the  loss  of  nitrogen  is  21  per 
cent. ;  while  if  jaundice  is  present,  it  may  reach  33  per  cent. 

CARBOHYDRATES  IN  THE  STOOL.     PANCREATIC  DIASTATIC  FERMENTS 

Though  extirpation  of  the  pancreas  in  animals  causes  disturbance  of 
the  digestion  of  the  carbohydrates,  so  that  an  increased  proportion  of 
starch  ingested  reappears  with  the  feces,  Opie  holds  that  the  determination 
of  the  undigested  carbohydrates  in  the  human  being  acquires  no  signifi- 
cance for  the  diagnosis  of  pancreatic  disease. 

Robson  and  Cammidge  find  that  though  in  some  instances  of  pan- 
creatic disease  a  larger  proportion  of  carbohydrates  than  normal  is  found 
in  the  feces,  this  is  not  constant  even  in  marked  cases.  The  fact  that 
the  patient,  in  spite  of  an  abundant  carbohydrate  diet,  loses  weight, 
points  to  a  diminished  assimilation  of  carbohydrates  in  excess  of  the 
conditions  indicated  by  the  feces,  and  hence  the  figures  given  by  analysis 
of  the  stool  are  not  the  true  index  of  the  loss  of  carbohydrates  to  the 
organism. 

The  difference  between  the  quantity  assimilated  and  that  found  in  the 
stools  is  probably  explained  by  bacterial  action. 

The  influence  of  a  pathologic  condition  of  the  fecal  flora  (see  Testing 
the  Intestinal  Functions)  must  also  be  considered.  Hyperchlorhydria 
would  be  productive  of  fermentation  of  the  carbohydrates  in  the  stomach, 
and  catarrh  of  the  intestines  would  have  an  influence.  One  is,  therefore, 
compelled  to  arrive  at  definite  conclusions  after  a  process  of  careful 
elimination. 

Wohlgemuth^  introduced  the  method  of  estimating  the  diastatic 
ferments  in  the  feces. 

Wynhausen^  employs  the  following  method: 

"Five  c.c.  of  a  I  per  cent,  solution  of  soluble  starch  (Kahlbaum) 

1  Zeit.  f.  Klin.  Med.,  1891,  xiv,  294. 
^Lyle,  N.  Y.  Med.  Jour.,  May  28,  1910. 
3  Zeitschr.  fur  Biochemie,  ix,  1908. 
*  Berlin.  Klin.  Woch.,  July,  1909,  p.  1406. 


986  DISEASES    OF   THE    STOMACH    AND   INTESTINES 

are  each  placed  in  several  test-tubes  of  the  same  size,  and  graduated 
quantities  of  the  filtrate  of  a  thin  stool  are  added  to  each.  The  tubes 
are  placed  in  an  incubator  at  4o°C.  for  twenty-four  hours.  At  the 
end  of  this  period  they  are  filled  to  within  a  finger-breadth  of  the  top 
with  distilled  water.  To  each  is  then  added  i  drop  of  one-tenth  normal 
solution  of  iodin  and  the  resulting  color  is  noted.  If  the  starch  is  un- 
digested, a  blue  color  results;  if  erythrodextrin  is  present,  it  is  red;  if 
complete  digestion  has  occurred  (achroodextrin),  the  solution  is  colorless. 

"To  calculate  the  amount  of  ferment,  if  i  c.c.  of  the  filtrate  digests 
I  c.c.  of  soluble  starch  (Kahlbaum)  in  twenty-four  hours  at  38°C.,  the 
filtrate  has  a  concentration  of  one  diastatic  unit.  If  one-tenth  of  i  c.c.  of 
the  filtrate  is  added  to  5  c.c.  of  the  starch  solution,  and  the  mixture  is 
colorless  on  adding  i  drop  of  the  decinormal  iodin  solution,  digestion 
has  taken  place.  Therefore,  i  c.c.  of  the  filtrate  added  to  i  c.c.  of  the 
starch  solution  equals  10  X  5  or  50  units." 

Wynhausen  believes  the  normal  number  of  units  should  be  about 
500  to  600,  or  even  up  to  2000.  If  the  total  number  of  units  is  as  low 
as  50  to  60,  there  is  an  interference  with  the  flow  of  pancreatic  juice. 
Lyle  shows  that  considerable  caution  must  be  exercised  in  this  estimation, 
as  the  units  may  be  only  60,  with  a  normal  evacuation,  and  in  the  same 
case,  after  a  dose  of  Carlsbad  salts,  be  increased  to  600.  The  method  of 
producing  the  stool  must,  therefore,  be  considered. 

Fedeli^  and  Romani  describe  the  following  method  for  estimating  the 
diastatic  function  of  the  pancreas: 

"To  I  c.c.  of  saliva  add  5  c.c.  of  the  patient's  gastric  juice.  Shake 
the  mixture,  and  in  half  an  hour  add  sufiicient  of  a  i  per  cent,  sodium 
carbonate  solution  to  render  it  slightly  alkaUne.  To  this  add  20  c.c.  of 
a  10  per  cent,  starch  paste  and  place  in  a  thermostat  at  37°C.  for  two  hours, 
shaking  it  repeatedly. 
-  "Estimate  the  amount  of  sugar  formed. 

"Then  add  10  c.c.  of  an  aqueous  solution  ^i  -A)  of  feces  to  the  above, 
and  leave  in  an  incubator  for  twelve  hours,  when  the  sugar  formed  is 
again  estimated.  The  difference  between  the  two  quantities  of  sugar 
represents  the  degree  of  pancreatic  diastatic  function." 

GENERAL  CHARACTER  OF  THE  STOOL 

With  advanced  pancreatic  disease  the  stools  are  frequently  bulky, 
soft,  white,  and  usually  have  an  acid  reaction  and  a  peculiar  odor.  This 
appearance  does  not  always  occur,  however.  There  is  an  abnormal 
quantity  of  undigested  material,  especially  of  fat,  and  also  marked 
fermentation  is  present. 

Reaction  of  tiie  Stool. — Out  of  80  cases  of  pancreatic  disease  reported 
by  Robson  and  Cammidge,  the  fresh  feces  had  an  acid  reaction  in  58 
patients;  in  16  they  were  neutral  or  amphoteric,  and  in  6  they  were 
alkaline. 

Jaundice  appeared  to  exert  little  effect  on  the  reaction  of  the  stools 
when  the  pancreas  was  also  diseased.  With  jaundice  A\athout  pancreatic 
^  Riforma  Medica,  Sept.  20,  1909. 


METHODS    OF    DIAGNOSIS    IN    PANCREATIC    DISEASE  987 

disease,  and  in  patients  where  calculi  were  present  in  the  biliary  passages, 
but  no  bile-pigment  in  the  urine,  the  stools  were  usually  alkaline. 

The  peculiar  sour  odor  of  the  stools  in  pancreatic  cases  is  probably 
due  to  the  free  fatty  acids. 

In  the  fatty  stools  of  jaundice  Strassburger  noted  a  diminution  in  the 
number  of  bacteria,  and  probably  there  is  a  lessened  degree  of  intestinal 
putrefaction  in  these  cases,  even  though  the  bile  is  believed  to  possess 
antiseptic  properties.  If,  however,  the  amount  of  protein  is  increased, 
putrefaction  may  occur  as  a  result  of  affections  of  the  pancreas  or  intestines, 
and  the  feces  may  become  alkaline. 

Enteritis  or  chronic  colitis,  which  may  be  associated  with  pancreatic 
disease,  may  account  in  some  for  the  alkaline  reaction  of  the  stool. 

CHANGES  IN  THE  URINE  IN  PANCREATIC  DISEASE 

Indicanuria. — Opposing  theories  are  held  as  to  the  relation  of  pancreatic 
disease  to  indicanuria. 

.  Herter  believes  that  since  a  reduced  secretion  of  pancreatic  juice  is 
followed  by  an  impaired  digestion  of  proteins,  the  latter  are  liable  to  be 
attacked  by  bacteria,  the  urine  showing  the  signs  of  intestinal  putrefac- 
tion (indicanuria),  holding  that  on  exclusion  of  the  bile  and  pancreatic 
juice  there  is  an  excess  of  indican,  and  that  the  ethereal  sulphates  are 
increased,  their  proportion  to  preformed  sulphates  rising  to  i :  6  or  even 
1:1;  while  the  normal  proportion  is  i  :  10.  Other  observers  believe  that 
absence  of  indican  and  a  diminution  of  ethereal  sulphates  are  an  indication 
of  pancreatic  disease.  One  may  say  that  diminished  secretion  of  the 
pancreas  provides  conditions  under  which  putrefaction  may  occur. 

Robson  believes  that  the  presence  of  indicanuria  and  an  excess  of 
ethereal  sulphates  in  the  urine  probably  shows  an  associated  enteritis. 

Bile  in  the  Urine. — Diseased  conditions  of  the  pancreas,  or  chole- 
lithiasis which  may  obstruct  the  passage  of  bile  into  the  intestines,  may 
produce  jaundice,  and  the  appearance  of  bile  in  the  urine.  The  latter 
may  in  some  cases  be  of  a  deep  yellow  or  brown  color,  and  gives  the  reaction 
for  bile-pigment.     Bilious  urine  and  jaundice  are  not  constantly  found. 

Urobilin.— If  the  bile  is  completely  shut  of  from  the  intestines,  no  urobilin 
is  found  in  the  urine.  When  urobilin  is  present  in  the  urine,  there  is  some 
escape  of  bile  into  the  intestines,  even  though  there  is  an  apparently 
complete  obstruction  of  the  duct. 

Azoturia. — An  increased  excretion  of  nitrogen  compounds  in  the  urine 
is  believed  to  result  from  disturbances  of  intestinal  digestion,  and  to  be 
closely  related  to  putrefactive  changes  in  the  intestines.  This  condition 
is  not  constant  in  diseases  of  the  pancreas,  though  it  does  occur  with 
diabetes.  In  many  cases  of  pancreatitis  the  excretion  of  urea  is  not 
excessive  and  the  total  nitrogen  is  within  normal  limits. 

Phosphates. — These  are  stated  by  some  to  be  increased  in  diseases  of 
the  pancreas,  but  there  is  probably  no  marked  variation.  This  is  true 
also  of  the  chlorids. 

Acetonuria. — Experimentally,  extirpation  of  the  pancreas  in  animals 
may  result  in  the  appearance  of  acetone,  diacetic  aci-d.  and,  at  times,  of 


988  DISEASES    OF    THE    STOMApH    AND    INTESTINES 

j8-oxybutyric  acid  in  the  urine.  Acetone  and  diacetic  acid  have  been 
found  in  the  urine  in  a  large  percentage  of  cases  of  acute  pancreatitis,  and 
in  nearly  one-third  of  the  cases  of  chronic  pancreatitis  and  of  malignant 
growth  which  have  been  examined  for  these  bodies.  Acetone  bodies 
occur  with  diabetes,  with  wasting  diseases,  in  postanesthetic  poisoning, 
with  gastro-intestinal  diseases,  with  the  cyclic  vomiting  of  children,  with 
the  toxemic  vomiting  of  pregnancy,  with  puerperal  eclampsia,  with  phos- 
phorous-poisoning, with  acute  yellow  atrophy  of  the  liver  and  other  dis- 
eases of  that  organ,  with  fevers,  with  scurvy,  starvation  (especially  in 
women  and  children),  etc.  Carbohydrate  starvation  may  also  produce 
acidosis.  The  condition  is  not  idiopathic  to  pancreatic  diseases  or  to 
pancreatic  diabetes.  It  is  now  believed  that  the  acetone  bodies  are 
formed  chiefly  from  the  storage  fats  within  the  system,  and  not  within 
the  intestinal  tract. 

Calcium  Oxalate. — These  crystals  have  been  found  in  many  cases  of 
chronic  pancreatitis,  and  diabetes  has  been  occasionally  observed  to  follow 
long-continued  oxaluria.  Part  of  the  calcium  oxalate  is  undoubtedly 
derived  from  the  food,  and  oxaluria  may  be  the  direct  result  of  intestinal 
fermentation.  The  writer  believes  it  has  tio  significance  as  to  pancreatic 
disease. 

Carbohydrates. — Alimentary  Glycosuria. — The  liver  is  limited  in  its 
ability  to  transform  glucose  into  glycogen,  and  if  an  excess  of  sugar  is 
absorbed  from  the  alimentary  tract  the  quantity  of  sugar  in  the  blood  is 
increased  and  is,  consequently,  excreted  in  the  urine  (alimentary  gly- 
cosuria). A  normal  person  can  assimilate  from  150  to  250  grams  of  glucose 
after  fasting.  Therefore,  Kraus  advises  giving  100  grams  of  dextrose 
(grape-sugar)  in  250  c.c.  of  tea  or  water  two  hours  after  breakfast,  on  the 
fasting  stomach,  and  testing  the  urine  for  sugar  two  or  three  hours  later. 
If  this  is  found,  there  is  a  possibility  of  pancreatic  disease,  showing  the 
metabolic  function  of  the  pancreas  is  at  fault. 

Temporary  glycosuria  occurs  with  a  variety  of  injuries  or  operations 
on  the  nervous  system,  with  neurasthenia,  traumatic  neurosis,  some 
forms  of  mental  debiHty,  after  the  use  of  large  quantities  of  carbohy- 
drates, acute  febrile  conditions,  alcoholism,  with  exophthalmic  goiter, 
acute  diseases  of  the  brain  and  meninges,  mania,  paralysis,  and,  in  some 
cases,  with  cirrhosis  of  the  liver.  It  is  present  with  asphyxiation,  carbon 
monoxid  poisoning,  after  an  excessive  dose  of  morphin,  curare,  etc.  It 
shows  pancreatic  disease  to  be  present  in  about  65  per  cent,  of  cases. 
Persistent  glycosuria  is  suggestive  of  diabetes.  Fehling's  test  will  disclose 
the  presence  of  sugar. 

The  Cammidge  Pancreatic  Reaction. — This  reaction  consists  in  the 
demonstration  in  the  urine,  when  treated  by  a  special  chemic  procedure, 
of  certain  crystals  of  a  definite  morphology  and  a  certain  characteristic 
solubility.  Their  composition  is  unknown,  according,  to  Cammidge, 
though  the  substance  on  hydrolysis  yields  a  body  giving  the  reactions  of 
pentose,  probably  an  osazone.  The  specific  reaction  that  is  secured  is 
believed  to  be  due  to  an  inflammation  of  the  pancreas.  It  has  also  been 
found  in  a  percentage  of  cases  of  carcinoma  of  the  pancreas,  due  to  an 
inflammatory  zone  about  the  neoplasm. 


METHODS    OF   DIAGNOSIS   IN    PANCREATIC   DISEASE  989 

The  "A-reaction"  and,  later,  a  differential  test,  the  " B-reaction," 
were  first  employed.  It  was  found  that  errors  in  technic  were  apt  to 
occur,  and  that  much  depended  on  the  individual  equation.  The 
"improved"  or  "C-reaction"  is  now  employed. 

The  technic  of  C-reaction,  as  described  by  Cammidge,  is  as  follows: 

"The  urine  should  be  freed  from  albumin  by  boiling  with  acetic  acid 
and  from  sugar  by  fermentation,  when  they  are  present.  Then  filter  it 
several  times  through  the  same  paper.  A  specimen  of  the  twenty-four- 
hour  urine  should  be  employed,  though  the  mixed  night  and  morning 
specimen  can  be  used. 

"  Forty  c.c.  of  the  clear  filtrate  are  mixed  with  2  c.c.  of  strong  hydro- 
chloric acid  (sp.  gr.  1.16),  and  the  mixture  is  gently  boiled  on  a  sand-bath 
in  a  small  flask  which  is  fitted  with  a  funnel  condenser.  The  flask  is 
cooled  in  a  stream  of  water  and  the  contents  made  up  to  40  c.c.  with  cold 
distilled  water.  Then  8  grams  of  lead  carbonate  are  slowly  added  to 
neutralize  the  excess  of  acid,  and  the  solution  should  be  allowed  to  stand 
a  few  minutes.  It  is  again  cooled  in  running  water  and  filtered  through  a 
well-moistened  and  close-grained  filter-paper  until  the  contents  are 
perfectly  clear.     Several  filtrations  may  be  required. 

"The  acid  filtrate  is  shaken  well  with  8  grams  of  tribasic  lead  acetate 
and  the  resulting  precipitate  filtered  out.  A  clear  filtrate  should  be 
secured,  filtering  being  performed  several  times  if  necessary. 

"The  excess  of  lead  in  solution  is  removed  by  a  stream  of  sulphuretted 
hydrogen  or,  preferably,  the  filtrate  is  shaken  well  with  4  grams  of 
powdered  sodium  sulphate,  and  the  mixture  then  heated  to  the  boiling- 
point.  It  is  then  cooled  to  as  low  a  temperature  as  possible  in  a  stream 
of  running  water  and  the  white  lead  sulphate  precipitate  is  filtered 
out. 

"Ten  c.c.  of  the  clear,  transparent  filtrate  are  diluted  up  to  17  c.c.  with 
distilled  water,  and  to  it  are  added  2  grams  of  sodium  acetate,  0.8  grams  of 
phenylhydrazin  hydrochlorate,  and  i  c.c.  of  a  50  per  cent,  acetic  acid. 
This  is  placed  in  a  small  flask  with  a  funnel  condenser  and  boiled  in  a 
sandbath  for  ten  minutes.  It  is  filtered  while  hot  through  a  small 
filter-paper  moistened  with  hot  water  into  a  test-tube  provided  with  a 
15  c.c.  mark.  If  the  filtrate  falls  short  of  the  15  c.c.  mark,  it  is  made  up 
to  this  point  by  the  addition  of  hot  distilled  water,  and  the  mixture  is 
stirred  with  a  glass  rod.  In  well-marked  cases  of  pancreatic  inflamma- 
tion a  light  yellow  flocculent  precipitate  should  appear  in  a  few  hours, 
but  in  less  marked  cases  it  may  be  necessary  to  leave  the  preparation 
over  night." 

Under  the  microscope  the  precipitate  is  found  to  consist  of  long,  flexible, 
light  yellow  and  hair-like  crystals,  arranged  in  delicate  sheaves  (Fig.  414), 
which  disappear  in  ten  to  fifteen  seconds  when  irrigated  with  a  33  per 
cent,  solution  of  sulphuric  acid  A  microscopic  examination  must  always 
be  made. 

Cammidge  recommends  a  control  experiment  to  exclude  traces  of 
sugar  which  may  be  undetected  by  the  ordinary  tests.  He  treats  40 
c.c.  of  urine  in  the  same  way  as  just  described,  only  that  it  is  not  boiled 
with  hydrochloric  acid. 


990 


DISEASES   OF    THE    STOMACH   AND   INTESTINES 


The  urine  should  be  fresh,  and  if  alkaline  should  be  acidified  with 
hydrochloric  acid  before  testing. 

Dextrose,  when  present,  should  be  removed  by  fermentation  after 
the  urine  has  been  boiled  with  the  hydrochloric  acid,  and  the  excess 
neutralized.  If  calcium  chlorid  has  been  given,  which  is  advocated  in  all 
pancreatic  cases  before  operation,  it  interferes  with  the  test. 

Robson  and  Cammidge^  report  the  reaction  positive  in  every  case 
of  acute  and  chronic  pancreatitis — 67  cases  in  all;  and  that  in  16  cases 
of  carcinoma  it  was  found  in  4  (25  per  cent.).  In  50  normal  cases  it 
was  abseht,  while  in  117  cases  of  gall-stones,  etc.,  with  no  pancreatic 
disease,  it  was  present  only  four  times.  In  75  per  cent,  of  diabetics 
there  was  a  positive  result. 


■  ^w^w^m. 


"V 


Fig  414. — Improved  or  C-  ("pancreatic")  reaction  crystals  from  a  case  of  chronic 
pancreatitis  with  gall-stones  in  the  common  bile-duct  (X  200)  (Robson  and  Cam- 
midge). 

Opie^  States  that  the  pancreatic  reaction  has  been  obtained  in  a 
large  number  of  cases  in  which  pancreatic  disease  has  been  demon- 
strated or  suspected;  but  the  reaction  may  occur  without  pancreatic 
disease  and  is  sometimes  absent  when  a  lesion  of  the  gland  is  present. 

There  have  been  various  reports  both  for  and  against  this  reaction. 

Deaver'  reports  154  reactions,  and,  more  recently,  197  additional 
cases,  and  now  summarizes  351  in  all.^ 

In  all  the  cases  in  which  the  condition  of  the  pancreas  was  accurately 
determined  by  Deaver  at  the  time  of  operation,  the  pancreatic  reaction 
was  obtained,  on  an  average,  only  two  and  a  half  times  as  frequently 
when  the  pancreas  was  affected  as  when  it  was  not.     Recently  he  finds 

^  The  Pancreas. 

2  Disease  of  the  Pancreas,  1910. 

^  Amer.  Jour.  Med.  Sci.,  Dec,  1910. 

*  Jour.  Amer.  Med.  Assoc,  .^pril  15,  1911. 


METHODS    OF    DIAGNOSIS    IN    PANCREATIC    DISEASE  991 

onl\'  about  25  per  cent,  positive  reactions  corresponding  to  operative 
findings.^  Later  reports^  state  he  has  been  unable  to  derive  any  assistance 
from  this  reaction. 

Roper  and  Stillman^  carried  out  a  series  of  studies  on  the  Cammfdge 
reaction,  and  found  that  results  varied  in  the  same  patient,  apparently 
due  to  accidental  occurrences. 

They  conclude  that  the  C-reaction  of  Cammidge  does  not  rest  on  a 
sound  scientific  basis. 

The  author  has  tested  the  reaction  in  a  number  of  patients.  In 
a  recent  case,  for  example,  of  far-advanced  chronic  pancreatitis  with 
marked  steatorrhea,  repeated  examinations  showed  a  negative  Cam- 
midge. He  must  confess  that  he  has  been  disappointed  in  his  results 
secured  as  an  aid  to  diagnosis.  He  rarely  employs  it  and  is  skeptical  as 
to  its  value. 

Other  Urinary  Tests  in  Pancreatic  Disease, — Wohlgemuth  has 
advised  estimating  the  diastatic  ferment  in  the  urine  as  a  means  of 
diagnosis  of  pancreatitis. 

He  suggests  in  a  suspected  case  that  the  urine  should  be  examined 
daily,  and  a  decided  increase  in  the  diastatic  ferments  should  be  regarded 
as  indicating  an  interference  to  the  flow  of  the  pancreatic  juice. 

If  I  c.c.  of  urine  digests  i  c.c.  of  soluble  starch  (Kahlbaum)  in  twenty- 
four  hours  at  38°C.,  this  urine  has  a  diastatic  concentration  of  one  diastatic 
unit. 

The  formula  for  y  c.c.  of  urine  and  k  c.c.  of  starch  is  — —  X  5  (i  c.c. 
•^  y  c.c.      ^ 

starch)  =  diastatic  unit. 

Fat-splitting  Ferment. — Opie'*  found  in  one  case  of  acute  pancreatitis 
with  fat  necrosis  evidence  of  a  fat-splitting  enzyme  in  the  urine. 

Hewlett"  has  also  demonstrated  experimentally  that  an  injury  to  the 
pancreas  may  cause  a  fat-splitting  enzyme  to  appear  in  the  urine.  In 
subacute  and  chronic  pancreatitis  Robson  and  Cammidge  found  no  fat- 
splitting  enzyme  present. 

Lipnria. — Bowditch  and  Clark  describe  the  appearance  of  fat-lobules 
in  the  urine  in  cases  of  cancer  of  the  pancreas.  They  have  also  been 
found  in  acute  pancreatitis,  and  Robson  reports  them  in  one  case  of  chronic 
pancreatitis.  Lipuria  at  times  occurs  with  diabetes  mellitus.  It  has 
been  found  in  other  conditions  and  is  not  diagnostic  of  pancreatic  disease. 

THE  BLOOD  IN  DISEASES  OF  THE  PANCREAS 

In  the  more  chronic  and  more  advanced  cases  there  is  generally  a 
secondary  anemia,  with  reduction  in  the  red  cells.  The  hemoglobin 
does  not  seem  to  suffer  a  proportional  decrease  with  the  red  cells  and  the 
hemoglobin  index  may  even  be  quite  high.     Often  the  ratio  of  the  leu- 

*  Ibid.,  July  I,  1911. 

2  N.  Y.  Med.  Jour.,  Mar.  23,  1912. 

2  Arch,  of  Int.  Med.,  Feb.,  191 1,  pp.  252-258. 

*  Johns  Hopkins  Hosp.  Bull.,  1902,  xiii,  117;  also  Kastle  and  Loevenhart,  Amer. 
Chem.  Jour.,  1900,  xxiv,  No.  16. 

'=>  Jour,  of  Med.  Research,  1904,  xi,  377. 


992  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

kocytes  is  unaltered,  though  Woolsey  has  reported  leukocyte  counts  from 
17,600  to  39,000  in  three  cases  of  acute  pancreatitis.  The  polynuclears 
should  also  be  determined  in  acute  inflammation. 

Pancreatic  Hemolysin. — friedeman^  has  demonstrated  the  presence 
of  a  strongly  active  autohemolysin  in  the  pancreatic  juice,  and  that  when 
this  enters  the  circulation  through  tissue  destruction  it  brings  about  the 
same  results  as  other  hemolytic  substances.  In  some  pancreatic  affec- 
tions there  is  a  tendency  to  general  hemorrhage;  thus,  in  cancer  of  the  head 
of  the  pancreas,  in  pancreatitis  with  jaundice  (believed  to  be  partly  due 
to  cholemia),  and  also  in  pancreatitis  without  jaundice. 

Coagulation  of  the  Blood. — The  coagulation  time  of  the  blood  is 
increased.  This  feature  is  of  considerable  importance,  as  severe  postopera- 
tive hemorrhage  may  occur  in  cases  in  which  the  pancreas  is  involved. 
The  writer  believes  the  determination  of  the  coagulation  time  of  the  blood 
may  in  some  cases  be  of  assistance  in  diagnosis. 

Conclusions. — The  author  would  first  recommend  that  in  every  case 
of  suspected  pancreatic  disease  the  functions  of  the  stomach,  both  motor 
and  secretory,  should  be  examined,  so  that  the  digestive  function  of  this 
organ  can  be  taken  into  consideration  in  making  one's  deductions. 

The  general  test  of  the  intestinal  functions,  as  previously  described, 
by  the  Schmidt-Strassburger  diet,  should  then  be  made.  This  demon- 
strates whether  or  not  a  catarrhal  condition  of  the  intestine  is  present;  the 
presence  or  absence  of  bile,  the  influence  of  the  fecal  flora,  fermenta- 
tion and  putrefactive  conditions,  and  a  general  idea  of  the  quantity  of 
fat  present,  muscle-fibers,  starch,  etc.,  by  microscopic  examination 
This  alone  will  give  pretty  thorough  information  as  to  disturbance  of  the 
pancreatic  functions.     Reduction  of  split  fat  is  significant. 

For  the  general  practitioner,  the  Boldyreff  method  of  securing  the 
pancreatic  juice  is  the  most  simple  and  is  to  be  recommended.  Tests 
can  then  be  made  for  trypsin,  amylopsin,  and  steapsin. 

The  urine  should  always  be  examined  for  sugar.  The  Cammidge 
reaction  may  be  tested  for  as  routine,  though  its  value  is  doubtful.  Im- 
provement in  the  fecal  findings  after  administration  of  pancreatic  extract 
is  also  suggestive.  The  blood  examination  should  be  made  and  the  rapidity 
of  blood-clotting  determined. 

These  methods  of  examination,  when  employed  in  association  with 
the  clinical  symptoms,  will  be  of  most  service.  In  acute  conditions  par- 
ticularly, and  even  with  suspected  chronic  pancreatitis,  the  urine  should 
be  examined  for  colon  bacilli,  and  if  such  are  present,  proper  treatment 
instituted.  The  writer  later  reports  a  chronic  pancreatitis  with  colon 
bacillus  infection.  The  other  methods  described  are  of  chief  interest  to 
the  specialist. 

^  Deut.   Mediz  Wochenschr.,  1907. 


CHAPTER  XLI 

GENERAL   SYMPTOMS  AND  DIAGNOSIS  OF  PANCREATIC 

DISEASE 

One  might  suppose  that  on  account  of  the  important  part  that  the 
pancreas  takes  in  the  digestive  processes  in  the  intestines,  and  its  influence 
on  the  metaboHsm  of  the  body,  that  any  deviation  from  the  normal 
would  produce  such  functional  disturbances  that  a  diagnosis  of  pan- 
creatic disease  would  be  easy.  On  account  of  the  fulminating  symptoms, 
an  acute  disturbance  of  the  pancreas  is  much  more  readily  diagnosed  than 
the  chronic  conditions.  Unfortunately,  the  pancreas  is  seldom  diseased 
without  the  involvement  of  some  of  the  other  organs.  Thus,  cholelithiasis, 
gastro-intestinal  catarrh,  or  catarrh  of  the  biliary  and  pancreatic  ducts 
may  coexist;  or  tumors  or  ulcers  of  the  stomach  or  duodenum  may  in- 
volve the  pancreas.  Affections  of  the  liver,  lymphatic  glands,  or  colon 
may  also  produce  disease  of  the  pancreas. 

One  must  further  remember  that  the  stomach  can  care  for  the  pro- 
teins to  a  certain  extent,  that  the  salivary  and  intestinal  glands  can  digest 
starches,  and  that  the  bile  and  intestinal  juice  can  emulsify  fat;  further- 
more, the  intestinal  bacteria  can  break  down  various  food  stuffs,  and 
thus  interfere  with  the  pathologic  changes  in  the  stools,  such  as  would 
be  expected  in  disease  of  the  pancreas.  When  the  duct  of  Wirsung  is 
obstructed,  in  a  number  of  cases  the  pancreatic  secretion  may  escape 
through  the  duct  of  Santorini,  and,  moreover,  a  considerable  portion  of 
the  pancreas  may  be  diseased,  and  yet  a  sufficient  part  remain  healthy 
and  so  carry  on  the  functions  of  the  organ.  Sometimes,  though  the 
pancreas  maj''  be  primarily  at  fault,  the  most  prominent  symptoms  may  be 
produced  by  an  organ  that  is  secondarily  involved.  For  example,  marked 
jaundice  and  distention  of  the  gall-bladder  may  result  from  a  cancer  of 
the  head  of  the  pancreas  pressing  on  the  common  bile-duct,  or  from  pres- 
sure contraction  of  a  chronic  pancreatitis. 

Moreover,  as  in  a  recent  case  of  the  author's,  a  pancreatic  tumor 
may  compress  the  intestines  and  produce  intestinal  obstruction,  or  may 
press  upon  the  neighboring  ganglia  and  cause  such  excruciating  pain 
that  it  mimics  that  of  an  aneurysm  or  of  spinal  disease. 

All  these  factors  must  be  held  in  consideration. 

Anamnesis. — A  careful  history  of  the  case  is  of  great  importance.  Some 
patients  may  give  a  history  of  habits  of  eating  or  drinking  which  might 
set  up  an  inflammation  of  the  stomach  and  duodenum;  in  others  there 
may  be  a  history  of  infectious  conditions  which  are  liable  to  be  followed 
by  disease  of  the  biliary  passages;  or  there  may  be  a  preceding  history  of 
disease  of  the  bile-ducts  or  gall-bladder,  with,  in  some  cases,  attacks  of 
biliary  colic.  Males,  moreover,  seem  to  be  more  liable  to  pancreatic 
disease. 

63  993 


994  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

PHYSICAL  SIGNS 

Presence  of  Tumor. — The  position  of  the  pancreas,  lying  behind 
the  stomach,  renders  it  unfavorable  for  palpation,  and  often,  especially 
in  stout  persons,  it  cannot  be  felt  at  all.  If  the  patient  is  very  thin  and 
the  stomach  is  empty  and  the  abdominal  muscles  are  relaxed,  especially 
in  the  case  of  gastroptosis,  it  may  be  often  defined.  Frequently  in 
acute  and  chronic  inflammation,  and  even  in  the  case  of  abscess  of  the 
pancreas,  it  is  impossible  to  determine  enlargement  of  the  pancreas. 
In  the  acute  cases,  pain  and  rigidity  in  the  epigastrium  often  interfere 
with  the  determination  of  a  mass,  but  the  acute  fulminating  attack  and  the 
epigastric  peritonitis  are  themselves  suggestive.  Robson  claims  that  in 
many  cases  a  distinct  swelling  can  be  felt  due  to  the  enlarged  pancreas, 
with  an  effusion  of  blood,  inflammatory  fluid,  and  matted  omentum. 

Korte  describes  three  cases  in  which  the  mass  was  palpable  between 
the  stomach  and  colon. 

With  chronic  pancreatitis,  in  three  cases  only,  in  very  thin  patients,  was 
Deaver^  able  to  palpate  the  swollen  head  of  the  pancreas.  Palpation 
he  found  of  most  value  to  exclude  other  abdominal  conditions. 

With  cancer  of  the  head  of  the  pancreas,  the  only  tumor  usually  felt 
is  due  to  the  enlarged  gall-bladder. 

Occasionally,  tumor  of  the  body,  tail,  and,  at  times,  some  growths  of 
the  head  of  the  pancreas  can  be  distinguished  by  palpation.  The  writer 
has  recently  determined  one  such  by  palpation. 

By  inflating  the  stomach  with  carbonic  acid  gas  or  with  air  the  relation 
of  this  organ  to  the  tumor  can  be  made  out.  The  inflated  stomach 
separates  the  mass  from  the  liver.  Unless  the  stomach  is  empty,  there  is 
resonance  on  percussion  over  the  growth,  with  communicated  non- 
expansile  pulsation,  and  a  slight  movement  on  deep  inspiration.  Infla- 
tion of  the  colon  may  also  aid  at  times  in  localizing  the  mass.  With  cyst 
of  the  pancreas,  the  presence  of  a  tumor  may  be  for  a  time  the  only  symptom. 
Its  position  depends  on  from  what  part  of  the  pancreas  it  originates.  It 
is  found  in  various  situations,  which  are  described  under  Cyst  of  the 
Pancreas.  The  absence  of  tumor  does  not  prove  that  disease  of  the  pancreas 
is  not  present.  If  the  tumor  or  enlargement  of  the  organ  can  be  positively 
determined,  in  connection  with  other  symptoms,  it  affords  valuable  evidence 
of  a  lesion  of  the  pancreas. 

Pain. — Pain  in  acute  pancreatitis  is  one  of  the  important  symptoms. 
It  appears  suddenly  and  is  intense  in  character.  It  may  be  colicky, 
then  diminish  and  disappear,  and  return  later  (paroxysmal).  It  may 
at  times  be  continuous.  It  is  usually  located  in  the  epigastrium,  above 
the  umbilicus,  and  may  pass  from  the  median  line  along  the  course  of 
the  pancreas. 

Opie  notes  cases  in  which  the  pain  is  most  severe  in  the  hypochondriac 
regions  or  even  below  the  umbilicus. 

In  the  cases  of  chronic  pancreatitis  reported  by  Deaver^  pain  was  the 
leading  and  most  constant  symptom,  being  absent  in  only  thtee  cases.     It 

1  Jour.  Amer.  Med.  Assoc,  April  15,  1911. 
*Jour.  Amer.  Med.  Assoc,  April  15,  igii. 


GENERAL    SYMPTOMS    AND    DIAGNOSIS    OF    PANCREATIC   DISEASE      995 

varied  from  a  dull  discomfort,  fulness,  or  oppression  in  the  epigastrium 
to  an  ache  or  a  sharp,  lancinating,  coHcky  pain,  much  like  gall-stone  colic. 
In  the  cases  of  colicky  pain  he  found  the  gall-bladder  usually  also  diseased. 

In  many  cases  of  chronic  pancreatitis,  especially  in  the  early  stages, 
pain  may  be  absent  or  scarcely  noticed. 

There  is  no  definite  relation  to  eating  or  to  particular  articles  of  food 
in  the  production  of  the  pain.  In  this  it  differs  from  the  pain  produced 
with  gastric  or  duodenal  ulcer,  and  thus  may  be  of  some  aid  in  differential 
diagnosis. 

The  carbohydrates  in  some  cases  seem  to  cause  the  most  digestive 
disturbances,  and  Sailer  has  found  that  the  administration  of  glucose  to 
test  the  limit  of  assimilation  to  be  particularly  distressing.  Intestinal 
fermentation  is  undoubtedly  the  cause  of  this  feature. 

With  malignant  disease  of  the  pancreas,  pain  may  be  absent  in  some 
cases  and  present  in  others.  The  pain  may  be  very  severe,  due  to  pressure 
on  or  involvement  of  the  ganglia  or  adjacent  organs,  such  as  the  stomach 
and  duodenum.  On  the  other  hand,  the  writer  has  recently  seen  a  large 
carcinoma  of  the  outer  third  of  the  pancreas,  involving  the  stomach  also, 
in  which  all  symptoms  pointed  to  gradually  increasing  stenosis  of  the 
bowel.  Operation  demonstrated  pressure  stenosis  of  the  transverse  colon. 
The  patient  had  no  pain  from  the  tumor,  which  was  readily  palpable, 
and  only  suffered  from  cramps  when  attempting  to  have  a  bowel  action, 
with  dyspeptic  disturbances  and  progressive  loss  of  weight. 

Pancreatic  cysts  are  sometimes  painless,  though  pain  is  present  in 
some  cases. 

With  abscess  of  the  pancreas,  pain  is  frequently  present,  but  not 
invariably  so. 

Calculus  of  the  pancreas  may  exist  for  years  without  any  pain.  If 
the  calculus  progresses  to  the  orifice  of  the  pancreatic  duct  or  becomes 
impacted  in  the  ampulla  of  Vater,  severe  paroxysmal  pain  may  occur  which 
resembles  gall-stone  colic,  and  jaundice  may  be  associated.  The  pain 
may  become  continuous.  It  may  occur  in  the  epigastrium  or  radiate  to 
either  side  of  the  thorax. 

With  disease  of  the  pancreas,  the  pain  may  radiate  to  the  left,  to  between 
the  scapulae  or  under  the  left  scapula.  When  it  radiates  to  the  right  it 
resembles  gall-bladder  pain.  The  pain  may  also  radiate  to  the  cardiac 
region  and  resemble  that  of  angina  pectoris.  Pain  can  scarcely  be  called 
pathognomonic  of  any  particular  type  of  pancreatic  disease,  except  in 
the  case  of  acute  pancreatitis. 

Tenderness. — With  acute  pancreatitis  there  is  excessive  tenderness 
on  pressure  in  the  epigastric  region,  most  marked  at  Robson's  point 
(Fig.  415),  about  11-2  inches  above  and  slightly  to  the  right  of  the  umbilicus 
which  is  accompanied  by  muscular  rigidity  of  the  recti.  At  times  the 
tenderness  may  extend  along  the  course  of  the  pancreas,  and  Fitz  has 
noted  additional  sensitive  points  in  the  abdomen,  probably  due  to  the 
areas  of  fat  necrosis. 

With  chronic  pancreatitis  tenderness  may  be  absent,  though  in  the 
more  advanced  cases  it  may  be  present.  Deaver's  patients  were  operated 
upon  during  or  just  after  some  exacerbation  of  the  symptoms,  and  there 


996 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


was  some  degree  of  tenderness  in  most  of  them.  His  findings  were  variable 
as  to  location,  tenderness,  being  present  below  both  costal  margins,  more 
frequently  to  the  right,  in  the  mid-epigastrium,  at  Robson^s  point,  and  in  one 
case  general. 

Rigidity. — Rigidity  was  also  variable,  there  being  more  cases  in  the 
right  hypochondrium,  some  in  the  midepigastrium,  and  in  some  there  was 
moderate  distention. 

Tenderness  is,  as  a  rule,  absent  in  malignant  disease  of  the  pancreas, 
unless  from  pressure  or  involvement  of  the  nerve  plexuses  or  of  adjacent 
organs. 


Fig.  415. 


-Most  frequent  site  of  the  tender  spot  in  inflammatory  affections  of  the 
pancreas  ("Robson's  point")- 


With  pancreatic  abscess  tenderness  is  often  present,  but  it  may  be 
absent,  and  with  pancreatic  cysts  tenderness  is  more  usually  absent. 

With  calculus  of  the  pancreatic  duct  tenderness  is  often  absent,  unless 
the  calculus  becomes  impacted  in  the  ampulla,  when  tenderness  may  be 
associated  with  the  attacks  of  paroxysmal  pain. 


SYMPTOMS 


Nausea  and  Vomiting. — With  acute  pancreatitis  (hemorrhagic  or 
gangrenous)  vomiting  is  a  prominent  symptom.  It  is  frequently  so  violent 
and  obstinate  as  to  suggest  intestinal  obstruction.     The  vomiting  is  not 


GENERAL    SYMPTOMS    AND   DIAGNOSIS    OF   PANCREATIC   DISEASE     997 

stercoraceous,  and  there  is  no  visible  peristalsis  of  the  intestines,  such  as 
occur  with  acute  obstruction. 

In  other  types  of  pancreatic  disease,  vomiting  has  usually  been  con- 
sidered not  a  common  symptom,  and  when  it  occurs  it  is  often  due  to 
disturbances  of  the  stomach  or  duodenum. 

Opie  reports  four  cases  of  persistent  vomiting  associated  with  chronic 
interlobular  pancreatitis.  The  history  in  all  afforded  evidence  of  gastric 
or  gastro-intestinal  disease,  and  indicated  some  relationship  between  these 
disturbances  and  the  chronic  lesion  of  the  pancreas. 

Deaver^  reports  21  cases  of  chronic  pancreatitis  having  attacks  in 
which  vomiting  figured,  and  10  more  who  were  nauseated,  and  holds  that 
in  the  more  severe  types  of  chronic  pancreatitis  nausea  or  vomiting  may 
occur  in  attacks  at  variable  intervals.  When  vomiting  occurs,  it  is  not 
particularly  characteristic,  though  it  may  contain  mucus  and  bile.  If  an 
abscess  of  the  pancreas  has  ruptured  into  the  stomach,  pus  and  altered 
blood  may  be  vomited  up. 

Vomiting  of  Blood. — With  acute  pancreatitis,  altered  blood — ^Uofee- 
groufid"  or  so-called  '^black^^  vomit — may  be  vomited  up.  This  may  occur 
quite  early  in  association  with  the  tendency  to  general  hemorrhage.^ 
The  vomiting  of  blood  with  this  hemorrhagic  diathesis,  occurs  chiefly  with 
acute  pancreatitis,  in  pancreatitis  associated  with  jaunidce,  and  also  in 
cancer  of  the  pancreas,  though  also  in  other  types  of  pancreatic  disease. 

Jaundice. — Acute  hemorrhagic  pancreatitis  may  be  accompanied  by 
a  slight  jaundice  if  a  small  gall-stone  is  impacted  in  the  outlet  of  the 
ampulla  of  Vater.  There  is  a  well-known  relation  between  gall-stone 
disease  and  disease  of  the  pancreas.  The  relation  of  the  common  bile- 
duct  to  the  head  of  the  pancreas  is  the  determining  factor  in  many  cases 
as  to  the  appearance  or  absence  of  jaundice;  in  about  38  per  cent,  of 
cases  the  common  duct  lies  behind  the  head  of  the  pancreas,  so  that 
pancreatitis,  either  acute  or  chronic,  or  even  cancer  of  the  pancreas,  may 
run  its  course  without  the  appearance  of  jaundice.  In  about  62  per  cent, 
of  cases  the  common  duct  is  situated  in  a  deep  groove  or  is  imbedded  in  the 
head  of  the  pancreas,  so  that  either  pancreatitis  or  a  new  growth  will 
compress  the  bile-duct  and  lead  to  jaundice. 

Robson  reports  that  in  62  per  cent,  of  cases  of  chronic  pancreatitis 
with  cholelithiasis  bile-pigments  were  found  in  the  urine  before  opera- 
tion, while  in  38  per  cent,  neither  jaundice  nor  bile-pigment  was  present. 
In  the  case  of  chronic  pancreatitis  without  cholelithiasis  in  16  per  cent, 
there  was  jaundice,  due  either  to  an  ascending  catarrh  of  the  duodenum 
or  to  compression  of  the  common  duct. 

In  Deaver's  patients  with  chronic  pancreatitis  jaundice  was  present  in 
24  and  absent  in  14.  Jaundice  may  be  preceded  by  pain,  as  in  gall-stone 
colic,  though  usually  it  is  less  severe,  unless  a  stone  is  passing  through  theduct. 

Jaundice  is  not  a  constant  symptom.  Marked  jaundice  with  a  dis- 
tended gall-bladder  is  significant  of  cancer  of  the  head  of  the  pancreas. 
Jaundice  in  these  cases  develops  slowly  but  steadily,  and  usually  with- 
out pain.     The  patient's  skin,  as  the  cachexia  increases,  may  become  of  a 

^  Jour.  Amer.  Med.  Assoc,  April  15,  igii. 

-  Intestinal  hemorrhage  with  melena,  hemorrhages  from  the  nasopharynx  and  sub- 
cutaneous hemorrhage  may  occur. 


QpS  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

slaty  appearance,  a  "black  jaundice,"  instead  of  the  saffron  yellow  of 
cholelithiasis.  With  advanced  chronic  pancreatitis  jaundice  may  occur. 
When  a  gall-stone  in  the  common  duct  is  the  cause  of  the  jaundice,  the  gall- 
bladder is  usually  contracted,  and  often  cannot  be  felt  (Courvoisier's 
rule). 

Emaciation. — Emaciation  as  a  symptom  does  not  figure  in  acute 
inflammation  of  the  pancreas,  since  the  attack  is  fulminating  in  character 
and  of  short  duration.  In  the  typic  chronic  inflammation,  in  carcinoma 
or  cyst  of  the  pancreas,  and  in  diabetes  of  pancreatic  origin,  emaciation 
is  often  a  prominent  symptom.  The  loss  of  weight  is  frequently  marked. 
Due  to  disturbance  of  the  pancreatic  function,  digestion  is  impaired  and 
rapid  loss  of  weight  may  result.  It  is  sometimes  difficult  to  differentiate 
between  chronic  pancreatitis  of  a  severe  type,  with  rapid  loss  of  weight, 
and  carcinoma  of  the  pancreas. 

Loss  of  strength  may  accompany  the  loss  of  weight.  This  is  par- 
ticularly true  in  cases  of  severe  chronic  pancreatitis  with  associated 
jaundice,  and  also  in  cancer  of  the  pancreas. 

Temperature. — In  acute  hemorrhagic  pancreatitis  the  temperature 
may  be  normal  or  subnormal;  while  with  acute  gangrenous  and  acute 
suppurative  pancreatitis  the  temperature  may  be  considerable.  In  the 
last,  it  is  frequently  irregular  and  may  run  a  septic  type.  With  acute 
pancreatic  catarrh  the  temperature  resembles  that  of  infective  cholangitis. 
With  abscess  formation  there  may  be  a  persistent  temperature  of  ioo° 
to  io3°F.,  with  rigors  associated.  With  cancer  of  the  pancreas  the 
temperature  is  usually  subnormal,  though  occasionally  fever  from  asso- 
ciated complications  may  result.  Cysts  and  calculus,  as  a  rule,  are  not 
accompanied  by  fever. 

With  chronic  pancreatitis  the  temperature,  <w  a  rule,  is  normal,  but 
fever  may  occur  during  the  exacerbation  of  the  disease. 

Dyspepsia  and  Disturbance  of  Appetite. — There  may  be  anorexia, 
a  sensation  of  fulness  after  eating,  flatulence  with  eructations,  heart- 
burn, nausea,  and  distaste  for  fats  and  meat.  Sometimes  the  adminis- 
tration of  pancreatic  extracts  markedly  relieves  these  symptoms. 

Hemorrhage. — Reference  has  already  been  made  to  the  hemorrhagic 
tendency  which  is  found  with  inflammatory  disease  and  malignant  growths 
of  the  pancreas.  Bleeding  may  occur,  not  only  at  and  after  operation,  but 
at  other  times,  and  may  manifest  itself  by  hemorrhage  from  the  mucous 
surfaces,  stomach,  intestines,  etc.,  and  into  the  skin  or  subcutaneous 
tissues. 

Blood. — The  blood  frequently  shows  a  secondary  anemia,  and  leuko- 
cytosis and  increase  in  polynuclears  may  occur  with  the  acute  attacks. 
Clotting  may  be  delayed. 

Pressure  Symptoms. — With  disease  of  the  pancreas  ascites  may  at 
times  occur  due  to  tumor  pressure  on  the  portal  vein,  and  edema  of  the 
lower  limbs  from  pressure  on  the  inferior  vena  cava.  Enlargement  of 
the  spleen  and  hemorrhoids  may  also  result  from  pressure  on  the  portal 
vein.  Occasionally  the  duodenum  is  partially  or  completely  surrounded 
by  the  head  of  the  pancreas,  and  malignant  disease  or  inflammation  of 
the  pancreas  may  obstruct  the  passage  of  the  gastric  contents  and  produce 


GENERAL   SYMPTOMS    AND    DIAGNOSIS    OF    PANCREATIC   DISEASE     999 

dilatation  of  the  stomach  with  vomiting.  Obstruction  of  the  transverse 
colon  occurred  from  pancreatic  cancer  in  a  case  of  the  author's. 

Cysts  or  new  growths  of  the  pancreas  may  displace  the  stomach, 
duodenum,  or  colon.  The  stomach,  depending  on  the  position  of  the 
cyst,  may  be  pushed  up  under  the  diaphragm  or  down  below  the  umbilicus. 

Distention  of  the  gall-bladder  with  associated  jaundice  may  result 
from  cancer  of  the  head  of  the  pancreas,  and  also  from  chronic  pancreatitis, 
when  the  common  duct  passes  through  the  head  of  the  organ.  Occasion- 
ally the  hepatic  duct  is  pressed  upon  by  a  prolongation  of  the  diseased 
pancreas,  so  there  may  be  jaundice  without  distention  of  the  gall-bladder. 
If  a  pancreatic  cyst  presses  upward  against  the  diaphragm,  it  may  cause 
dyspnea,  and  this  may  also  be  produced  by  secondary  effusion  into  the 
lesser  peritoneal  sac.  Hydronephrosis  may  occasionally  be  caused  by 
pressure  of  pancreatic  tumors  on  the  ureter,  and  either  pressure  on  or 
involvement  of  the  solar  plexus  may  cause  pain. 

Liver. — The  liver  is  occasionally  enlarged  (cirrhosis),  with  diabetes. 

General  Circulation. — Symptoms  of  severe  shock  occur  with  acute 
pancreatitis,  and  the  pulse  becomes  so  rapid  and  feeble  that  cyanosis 
results. 

Bowels. — With  acute  pancreatitis  there  is  obstinate  constipation. 
With  pancreatic  disease  of  a  chronic  type,  constipation  is  a  frequent 
symptom ;  rarely,  diarrhea.  The  frequent  soft,  bulky  movements,  greasy 
and  of  pale  color,  described  as  characteristic  of  pancreatic  disease  of  the 
more  chronic  type,  are  found  in  the  most  advanced  cases  and  not  in  the 
earlier  stages  of  the  diseased  pancreas. 

Steatorrhea. — The  microscopic  appearance  of  fat  in  the  stools  is  a 
valuable  adjunct  in  determining  disease  of  the  pancreas.  One  must 
determine  whether  the  clay-colored  stool  is  due  to  the  presence  of  excess 
of  fat  or  fatty  acids,  or  to  absence  of  bile  from  the  intestinal  tract.  The 
presence  or  absence  of  stercobilin  in  the  stool  will  determine  this  last 
feature.  In  health  the  unabsorbed  fecal  fats  consist  approximately  of 
20  to  30  per  cent,  neutral  fat,  and  from  70  to  80  per  cent,  of  split  fat 
(fatty  acids  and  soaps).  In  cases  of  pancreatic  disease,  even  though  the 
total  percentage  of  fecal  fat  in  some  cases  may  not  be  increased  above 
the  normal,  the  ratio  of  split  fat  to  the  neutral  fat  is  always  decreased.  Katz 
has  asserted  that  a  diminution  of  the  split  fat  below  70  per  cent,  of  the 
total  fecal  fat  signifies  disease  of  the  pancreas,  except  in  nursing  infants 
and  patients  with  diarrhea.  Robson  and  Cammidge  hold  that  in  chronic 
pancreatitis  the  total  amount  of  unabsorbed  fat  may  reach  50  to  60  per 
cent.,  and  even  to  75  to  90  per  cent.,  with  malignant  disease  of  the  organ. 

Normal  stools  have,  however,  been  found  with  cases  of  pancreatic 
disease,  so  that  negative  findings  as  to  steatorrhea  or  split  fat  may  not  be 
co7iclnsive.     Positive  results  are  very  suggestive. 

Azotorrhea. — ^The  presence  of  muscle-fibers  in  the  feces  is  not  as 
constant  a  symptom. 

Sialorrhoea  Pancreatica. — An  increased  flow  of  saliva  has  been  noted 
by  a  few  observers  in  disease  of  the  pancreas,  especially  in  cases  of  pan- 
creatic calculi  and  in  cysts.     As  an  aid  to  diagnosis  it  cannot  be  relied  on. 

Glvcosuria  should  be  tested  for. 


lOOO  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

The  author  has  recommended  the  most  practical  tests  for  diagnosis 
at  the  end  of  the  section  entitled  "Methods  of  Diagnosis  in  Pancreatic 
Disease." 

Fat  Necrosis. — The  discovery  of  fat  necrosis  by  the  surgeon  on 
opening  the  abdomen  should  be  an  indication  for  exploration  of  the 
pancreas. 


CHAPTER  XLII 

INJURIES    OF   THE    PANCREAS— CLASSIFICATION    OF   ACUTE 
AND  CHRONIC  INFLAMMATION  OF  THE  PANCREAS- 
CATARRH  OF  THE  PANCREAS 

INJURIES  OF  THE  PANCREAS 

On  account  of  its  relation  to  other  important  viscera,  it  is  rare  for  the 
pancreas  alone  to  be  damaged  by  direct  violence  without  associated  injury 
to  other  organs. 

Injuries  of  the  pancreas  comprise  laceration  due  to  direct  violence, 
bullet  wounds,  and  penetrating  wounds. 

Laceration  due  to  Direct  Violence. — In  the  majority  of  cases  the 
force  which  produces  the  injury  has  been  directed  from  before  backward 
in  the  epigastrium,  and  lacerations  of  other  organs,  such  as  of  the  liver, 
kidney,  duodenum,  jejunum,  spleen,  or  fractured  ribs,  have  been  asso- 
ciated. In  such  cases  the  hemorrhage  from  the  other  injured  organs  has 
recently  been  so  severe  that  the  injury  to  the  pancreas  has  often  been 
overlooked.     Rarely,  the  pancreas  alone  may  be  lacerated. 

Etiology. — Falls,  a  blow,  a  kick,  crushing  between  two  vehicles,  or 
the  passage  of  a  vehicle  over  the  abdomen  are  the  most  frequent  causes 
of  laceration.     Sometimes  the  injury  (blow)  may  be  apparently  slight. 

Symptoms. — In  some  cases  after  severe  injury,  shock  and  the  immediate 
symptoms  of  internal  hemorrhage  may  occur,  and  operation  will  alone 
determine  the  character  of  the  injury.  In  others,  there  may  be  only  a 
slight  hemorrhage  into  the  pancreas  as  a  result  of  the  injury,  and  shortly 
acute  pancreatitis  follows;  or  the  patient  may  slowly  recover  from  the 
blow,  shock  pass  off,  and  within  a  few  days  to  a  few  weeks  an  abdominal 
tumor  may.  appear.  In  this  event  laceration  of  the  posterior  layer  of  the 
lesser  peritoneal  sac  has  occurred,  and  blood  and  the  pancreatic  secre- 
tion are  poured  into  the  lesser  peritoneal  cavity;  adhesions  close  the 
foramen  of  Winslow  and  a  pseudocyst  of  the  pancreas  results. 

It  occupies  the  epigastric,  umbilical,  and  left  hypochondriac  regions, 
as  a  rule.  The  stomach  and  transverse  colon  usually  lie  in  front,  and  the 
descending  colon  behind  and  to  the  left. 

Treatment. — The  immediate  shock ^  should  at  first  receive  treatment, 
and  as  soon  as  reaction  occurs,  immediate  laparotomy  should  be  under- 
taken and  an  attempt  be  made  to  secure  the  bleeding  points.  Suture  of 
the  torn  pancreas  should  be  performed.  If  other  viscera  are  lacerated 
the  condition  is  complicated,  but  repair  should  be  undertaken. 

In  cases  of  acute  pancreatitis  following  hemorrhage  due  to  traumatism, 
incision  and  drainage  of  the  pancreas  are  indicated,  and  when  a  pseudocyst 
of  the  pancreas  forms  subsequent  to  injury  it  should  be  incised  and 
drained. 

'  Application  of  heat,  hot  saline  enema,  morphin  w  grain,  strychnin  Jio  grain  and 
camphor  (in  sterile  almond  oil)  lo  grains  by  hypodermic  are  indicated. 


I002  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Bullet  Wounds  of  the  Pancreas. — In  the  majority  of  instances  other 
viscera  have  also  been  perforated  as  well  as  the  pancreas.  President 
McKinley,  for  example,  w^s  wounded  in  the  stomach,  pancreas,  and  left 
kidney.     Rarely,  the  lesser  omentum  and  pancreas  may  alone  be  injured. 

Symptoms. — There  are  no  symptoms  pathognomonic  to  a  wound  of 
the  pancreas.  The  probable  , course  of  the  bullet  is  the  only  guide. 
When  the  stomach  and  lesser  omentum  are  found  to  be  wounded, 
particular  examination  of  the  pancreas  should  be  made.  The  only  symp- 
toms are  of  shock  and  hemorrhage  taken  in  association  with  the  visible 
perforating  wound. 

Treatment. — Shock  should  be  treated.  ^  Operation  is  indicated.  Bleed- 
ing points  should  be  tied.  The  injured  organ  should  be  sutured  and  proper 
drainage  instituted. 

Penetrating  Wounds  of  the  Pancreas. — Penetrating  wounds  of  the 
pancreas  have  been  reported  as  a  result  of  stabs  with  a  knife  or  bayonet. 

In  some  cases  the  pancreas  protruded,  and  was  either  returned  or  the 
projecting  portion  resected.  These  cases  recovered.  Injuries  of  other 
viscera  were  associated. 

Symptoms. — They  consist  of  shock  and  internal  hemorrhage. 

Treatment. — This  is  the  same  as  that  described  for  gunshot  wound. 

As  a  result  of  injuries  to  the  pancreas,  acute  pancreatitis  (hemor- 
rhagic), a  pseudocyst  of  the  pancreas,  a  true  pancreatic  cyst,  abscess  of  the 
pancreas,  protrusion  of  the  pancreas,  and  prolapse  of  the  pancreas  may  occur. 

CLASSIFICATION  OF  ACUTE  AND  CHRONIC  INFLAMMATION  OF  THE 

PANCREAS 

Undoubtedly,  inflammatory  affections  of  the  pancreas  are  much  more 
frequent  than  were  formerly  supposed.  We  owe  much  to  the  surgeons 
who  have  demonstrated  the  frequency  of  pancreatic  disease,  and  its 
particularly  close  association  with  disease  of  the  gall-bladder. 

As  far  back  as  1672  Tulpius  described  a  diffuse  abscess  of  the  pancreas, 
and  Baillie,  in  1799,  a  hard  pancreas,  evidently  a  case  of  chronic  inter- 
stitial pancreatitis.  In  1804  Portal  described  a  case  of  acute  suppurative 
pancreatitis,  and  Percival,  in  181 8,  one  of  pancreatic  abscess  with  jaundice. 
In  1879  Balzer  first  described  acute  pancreatitis  with  fat  necrosis.  Fitz 
first  placed  inflammatory  diseases  of  the  pancreas  on  a  practical  basis, 
and  Robson,  chronic  pancreatitis  and  the  relation  of  gall-stone  disease  to 
disease  of  the  pancreas. 

Classification. — From  a  pathologic  standpoint  the  writer  believes 
that  Robson 's  classification  of  pancreatic  inflammation  is  the  best: 

(i)  Catarrhal  inflammations — acute,  chronic,  suppurative,  and 
pancreolytic  catarrh. 

(2)  Parenchymatous  inflammations  comprise  acute  hemorrhagic 
pancreatitis:  ultra-acute,  in  which  profuse  hemorrhage  precedes  inflam- 
mation; acute,  in  which  inflammation  precedes  hemorrhage;  gangrenous 
pancreatitis;  suppurative  pancreatitis  (diffuse  or  circumscribed).  Chronic 
inflammation  comprises  interstitial  pancreatitis  of  the  interlobular  or 
interacinar  type,  and  cirrhosis  of  the  pancreas. 

^  Hemorrhage  is  temporarily  treated  as  "  under  hemorrhage  of  gastric  ulcer." 


ACUTE    AND    CHRONIC   INFLAMMATION   OF    THE    PANCREAS  IOO3 

Etiology  of  Pancreatitis. — Among  the  predisposing  causes  of  pan- 
creatitis are  obstruction  in  the  ducts  or  papilla  of  Vater  resulting  from 
gall-stones,  duodenal  catarrh,  pancreatic  calculi,  cancer  of  the  head  of 
the  pancreas  or  of  the  papilla,  ulcer  of  the  duodenum  with  cicatricial 
stenosis  of  the  papilla,  and  lumbricoid  worms.  Injuries  to  the  epigastrium 
or  a  wound  may  produce  pancreatitis.  Among  other  predisposing 
causes  are  hemorrhage  into  the  pancreas,  general  diseases,  such  as  typhoid, 
influenza,  and  mumps,  anatomic  peculiarities  in  the  pancreas  or  its  ducts, 
atheroma  or  fatty  degeneration  of  the  blood-vessels,  back  pressure  from 
diseases  of  the  heart  and  lungs,  and  new  growths,  notably  cancer. 

Among  the  exciting  causes  are  infection  from  the  blood,  as  from  syphilis 
or  pyemia,  or  extension  from  the  duodenum,  as  with  gall-stone  obstruc- 
tion or  from  gastroduodenal  or  duodenal  catarrh;  or  from  adjacent  organs, 
as  from  gastric  or  duodenal  ulcer,  or  cancer  of  these  viscera  eroding  the 
pancreas. 

Tuberculosis  may  be  a  cause  of  infection,  and  alcohol  may  be  productive 
of  pancreatitis,  though  such  has  been  disputed. 

Bacterial  infection  has  been  disputed  in  its  causal  relation  to  pan- 
creatitis, though  colon  bacilli,  streptococci,  staphylococci,  etc.,  have  been 
found,  and  are  believed  by  many  to  be  secondary  invaders  of  injured  tissue. 
The  author  particularly  believes  the  colon  bacillus  to  be  a  factor  in  some 
cases,  either  from  a  general  infection,  or  through  the  duodenum,  and  later 
reports  a  case  of  advanced  chronic  pancreatitis  with  colon  b.  bacilluria. 

Since  the  ducts  of  the  pancreas  open  into  the  duodenum,  which  always 
contains  bacteria,  it  is  evident  that  infection  can  readily  occur  from  this 
viscus.  The  close  relation  of  the  pancreatic  to  the  common  bile-duct  is 
also  a  prominent  factor.  With  the  lodgment  of  a  calculus  in  the  common 
bile-duct,  an  infective  cholangitis  may  follow.  If  a  stone  passes  down 
into  the  pancreatic  portion  of  the  common  duct,  the  duct  of  Wirsung 
may  be  compressed,  and  the  secretion  of  the  pancreas  may  be  dammed 
back.  This  retained  secretion  may,  in  turn,  become  infected,  and  a 
catarrhal  inflammation  of  the  pancreas  result.  Even  if  the  stone  ulti- 
mately passes,  the  congested  and  swollen  pancreas  may  keep  up  pressure 
on  the  common  duct  and  cause  a  persistence  of  the  jaundice. 

With  persistent  jaundice,  due  supposedly  to  extension  into  the  common 
bile-duct  from  a  duodenal  catarrh,  probably  the  pancreatic  duct  is 
involved  in  many  cases. 

With  persistent  obstruction  from  a  gall-stone  a  suppurative  inflamma- 
tion of  the  pancreatic  and  common  bile-ducts  may  ensue,  and  if  this 
continues,  abscess  of  the  liver  and  pancreas  may  follow. 

With  the  milder  type  of  infective  catarrh  an  interstitial  pancreatitis 
may  result.  This  type  is  usually  of  the  interlobular  variety,  but  later 
the  islands  of  Langerhans  may  become  affected  and  diabetes  result. 

If  the  opening  of  the  ampulla  of  Vater  into  the  intestine  is  obstructed 
■by  a  gall-stone  (Fig.  416)  the  common  bile-duct  and  duct  of  Wirsung 
become  a  single  channel,  and  acute  hemorrhagic  pancreatitis  may  result 
from  the  entrance  of  bile  into  the  pancreas. 

From  the  above  observations  it  is  evident  that  gall-stones  in  the 
common  duct  and  in  the  ampulla  are  the  most  frequent  causes  of  the 
various  forms  of  pancreatitis. 


I004 


DISEASES   OF   THE    STOMACH   AND   INTESTINES 


In  a  certain  percentage  of  cases,  however,  the  bile-duct  and  duct  of 
Wirsung  open  by  separate  orifices  into  the  duodenum  (Fig.  416(6),  while 
in  others  the  duct  of  Santorini  is  the  chief  outlet  of  the  pancreas  or  is  of 
sufficient  size  to  take  on  the  functions  of  the  duct  of  Wirsung,  if  the  latter 
becomes  obstructed. 

In  the  case  of  injury  (traumatism)  to  the  pancreas,  it  is  believed  that 
the  secretion  of  the  gland  may  act  on  the  walls  of  the  blood-vessels  and 
produce  further  hemorrhage,  and  infection  from  the  duodenum  may  be 
an  additional  factor  in  causing  an  acute  inflammation. 

Hemorrhage  into  the  pancreas  may  also  arise  from  diseased  blood- 
vessels, and  the  injection  of  mercury  in  a  syphilitic  subject  has  been- 
reported  as  producing  acute  pancreatitis,  resulting  possibly  from  increased 
secretion  and  congestion  of  the  gland.  Syphilis  alone,  however,  may  be 
a  factor. 

Infection  of  the  biliary  passages  by  the  typhoid  bacilli  is  not  an  infre- 
quent occurrence,  and  in  one  case  they 
were  proved  to  be  the  factor  in  pancreatic 
catarrh.  Probably  influenza  and  some  of 
the  other  infectious  diseases  may  cause 
pancreatitis. 

Pancreatitis  has  been  reported  in  a 
number  of  cases  occurring  as  a  complica- 
tion of  mumps.  Out  of  652  cases  treated 
at  the  military  hospital  of  Val  de  Grace, 
Simonin  reports  10  cases,  or  1.3  per  cent., 
in  which  symptoms  of  pancreatitis  oc- 
curred from  the  first  to  the  twelfth  days 
of  the  disease,  and  which  lasted  from  two 
to  seven  days.  The  chief  symptoms  were 
epigastric  pain  and  tenderness  associated 
with  nausea  and  vomiting.  Jacob  re- 
ports a  case  in  which  a  tender  swelling 
was  found  in  the  epigastric  region  (an 
enlarged  pancreas);  and  Lemoine  and 
Lapasset  describe  a  case  occurring  on  the  fifteenth  day  in  which  autopsy 
showed  an  acute  inflammation  of  the  pancreas.  Epigastric  pain,  jaundice, 
and  hematemesis  were  the  chief  symptoms. 

With  pyemia,  one  has  the  general  symptoms  of  the  disease  with  the 
additional  epigastric  pain,  tenderness,  etc.,  when  the  pancreas  is  involved. 
Syphilis  may  affect  the  pancreas  as  a  tertiary  lesion  (gumma)  or  it  may 
be  congenital.  It  causes  an  interlobular  interstitial  pancreatitis.  Ulcera- 
tion of  the  stomach  or  duodenum  may  spread  to  the  pancreas  and  may 
produce  suppuration  in  that  organ.  The  relation  of  alcohol  to  the  pro- 
duction of  cirrhosis  of  the  pancreas  has  been  questioned.  It  has  been 
found  in  association  with  cirrhosis  of  the  liver,  and  the  writer  sees  no 
particular  reason  why  this  factor  should  not  be  identical.  Of  course, 
abuse  of  alcohol  may  produce  a  gastro-intestinal  catarrh,  which,  by  exten- 
sion, might  be  the  cause  of  the  chronic  pancreatitis.  Arteriosclerosis, 
the  result  of  alcohol,  might  again  be  the  cause  of  pancreatic  involvement. 


Fig.  416. — a,  Diagram  to  show 
how  a  small  gall-stone  may  obstruct 
the  papilla,  and,  if  the  ampulla  of 
Vater  be  very  large,  may  convert 
the  common  bile-duct  and  duct  of 
Wirsung  into  one  canal,  thus  pre- 
disposing to  acute  pancreatitis,  b, 
Diagram  to  show  a  method  of  ter- 
mination of  the  ducts  which  will  not 
predispose  to  pancreatitis  (Opie). 


CATARRH  OF  THE  PANCREAS  IOO5 

Cirrhosis  of  the  pancreas,  usually  resulting  in  a  fatal  diabetes,  in  some 
cases  undoubtedly  results  from  a  catarrh  of  the  ducts  of  long  duration, 
which  first  produces  an  interlobular  and  later  an  interacinar  pancreatitis. 
Unquestionably,  arteriosclerosis  may  be  a  cause  of  chronic  pancreatitis. 

FUNCTIONAL  DISTURBANCE  OF  THE  PANCREAS 
Pancreatic  Achylia 

Adolf  Schmidt  refers  to  a  secretory  disturbance  of  the  pancreas  which 
occurs  in  the  course  of  gastrogenic  intestinal  dyspepsia  resulting  from 
achylia  gastrica.  He  holds  that  ferment  tests  of  the  feces  alone  are  of 
little  value,  but  that  the  stools  should  be  examined  and  that  they  contain 
undigested  nuclei  and  show  creatorrhea  and  a  less  marked  steatorrhea  in 
these  cases.  A  careful,  examination  of  the  gastric  Junctions,  the  author 
believes  should  be  made,  as  in  his  opinion  a  positive  diagnosis  of  achylia 
gastrica  can  be  made  only  by  this  method. 

There  is  a  mild  form  of  acute  (or  rather  subacute)  pancreatitis  which 
may  occur  as  a  complication  of  disease  of  the  bile  passages  and  is  dis- 
tinguished from  pancreatic  achylia  by  an  onset  with  pain,  slight  fever, 
steatorrhea  marked,  but  an  absence  of  creatorrhea.  The  condition  is 
believed  to  be  due  to  the  relative  absence  of  bile,  which  is  the  chief 
activator  of  lipase. 

Unquestionably  with  acute  infectious  diseases  such  as  typhoid,  etc., 
there  are  disturbances  of  the  pancreatic  functions  with  diminution  of  its 
digestive  capacity      Disturbances  of  the  gastric  secretion  is  also  associated. 

CATARRH  OF  THE  PANCREAS 

Acute  Catarrh  of  the  Pancreas, — This  type  of  pancreatitis  resembles 
infective  cholangitis,  with  which  it  is  usually  associated,  and  is  generally 
due  to  a  stone  in  the  common  bile-duct  or  diverticulum  of  Vater,  with 
incomplete  obstruction.  The  process  is  undoubtedly  one  6f  extension 
into  the  pancreatic  duct.  The  writer  does  not  believe  that  infective 
cholangitis  and  acute  catarrhal  pancreatitis  can  be  differentiated,  and  thinks 
that  the  latter  is  a  sequel  to  the  former.  The  symptoms  of  infective 
cholangitis  are:  Variations  in  the  intensity  of  the  jaundice,  which  is  of 
long  duration,  usually  over  a  year;  the  liver  may  be  of  normal  size  or 
slightly  enlarged;  the  gall-bladder  is  not  distended;  the  spleen  is  enlarged; 
there  is  no  ascites;  bile  may  be  present  in  the  feces  continuously  or  occa- 
sionally; and  at  times  there  may  be  ague-like  paroxysms,  with  chilly  fever 
and  sweating  (the  hepatic  intermittent  fever  of  Charcot).  On  these 
occasions  there  may  be  colicky  pains  and  the  jaundice  deepens,  and 
often  nausea  and  vomiting  are  present.  The  chills  are  often  quite 
severe  and  the  temperature  may  rise  to  103°  to  io5°F.  Between  attacks 
the  temperature  is  normal.  Though  this  condition  may  continue  for 
years  without  suppuration  within  the  ducts,  the  process  is  one  of  infec- 
tion, and  operative  procedure  is  indicated,  i.e.,  the  removal  of  the  impacted 
stone.  The  infective  cholangitis  and  acute  catarrh  of  the  pancreas  are 
together  cured  by  this  method. 


IOo6  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Chronic  Catarrh  of  the  Pancreas. — The  possibility  of  diagnosing 
chronic  catarrh  of  the  pancreas  is  at  present  a  matter  of  much  dispute. 
Curtin^  believes  that  there  is  little  evidence  that  it  is  an  inflammatory 
process.  Lando^  holds  that  stagnation  of  the  pancreatic  secretion  within 
the  acini  may  produce  chronic  interstitial  pancreatitis. 

Robson^  and  Cammidge  believe  that  chronic  catarrh  of  the  pancreas 
can  usually  be  diagnosed  by  digestive  and  metabolic  symptoms  and  by 
swelling  of  the  gland,  and  that  the  symptoms  and  physical  signs  resemble 
in  a  mild  degree  those  of  chronic  pancreatitis. 

Etiology. — The  most  frequent  cause  of  chronic  catarrh  of  the  pancreas 
the  writer  believes  to  be  a  gastroduodenitis  or  duodenitis.  These  condi- 
tions may  be  either  acute  or  chronic,  and  as  a  result  an  infection  of  low 
grade  may  occur,  both  of  the  common  bile-duct  and  of  the  duct  of  Wirsung. 
While  a  catarrhal  condition  of  the  duodenum  exists,  as  can  be  determined 
by  the  microscopic  appearance  of  mucus  from  the  small  intestine,  "test- 
ing the  intestinal  functions"  will  be  of  value  chiefly  to  show  the  catarrh. 
This  last  will  interfere  with  the  secretion  of  the  prosecretin  and  entero- 
kinase,  and,  even  if  the  pancreatic  duct  were  not  involved,  or  to  a  slight 
extent,  and  the  common  bile-duct  were  chiefly  affected,  the  functions  of  the 
pancreas  would  be  interfered  with.  After  the  mucus  has  disappeared 
from  the  stools  and  jaundice  still  persists,  if  then  one  finds  the  pancreatic 
functions  markedly  disturbed,  the  assumption  of  catarrh  of  the  pancreatic 
duct  is  a  fair  one.  Moreover,  persistent  jaundice  following  the  history 
of  a  gastro-intestinal  or  intestinal  catarrh  shows  that  the  common  bile- 
duct  is  involved,  and  probably  the  pancreatic  duct. 

Treatment. — The  general  medical  treatment  is  that  of  duodenal 
jaundice  (see  Intestinal  Catarrh).  This  may  be  continued  for  the 
chronic  condition,  and  if  failure  results,  cholecystotomy  or  cholecysten- 
terostomy  may  be  performed,  which  will  relieve  the  catarrh  of  the  common 
bile-duct  and  take  off  pressure  from  the  pancreatic  duct. 

The  other  most  common  cause  of  chronic  pancreatic  catarrh  is  an 
impacted  stone  in  the  pancreatic  portion  of  the  common  bile-duct,  which 
presses  on  the  pancreatic  duct,  or  a  stone  in  the  ampulla. 

The  obstruction  is  usually  partial,  and  the  grade  of  infection  producing 
a  chronic  catarrh  is  low. 

The  history  is  one  of  gall-stone  attack,  followed  by  jaundice.  In  some 
cases  the  pancreatic  functions  may  be  disturbed.  One  must  remember 
that  in  some  the  duct  of  Santorini  may  take  on  in  part  the  function 
of  the  inflamed  duct  of  Wirsung,  so  that  the  examination  of  the  pan- 
creatic functions  may  not  afford  information.  Furthermore,  the  repeated 
passage  of  gall-stones  through  the  common  duct  may  set  up  a  catarrhal 
condition  which  may  extend  to  the  pancreatic  ducts. 

Regarding  the  determination  of  pancreatic  enlargement  in  chronic 
catarrh  of  the  pancreas  the  author  is  very  skeptical. 

The  removal  of  the  impacted  stone  affords  relief  both  to  the  catarrh 
of  the  common  bile-duct  and  to  that  of  the  pancreatic  duct. 

'  Phila.  Hosp.  Rep.,  1902,  v. 
2  Zeit.  f.  Heilk.,  1906,  Hft.  i. 
^  The  Pancreas:  Its  Surgery  and  Pathology. 


CATARKII    or    THE    PANCREAS 


1007 


In  a  large  percentage  of  cases  the  absolute  determination  and  early 
diagnosis  of  chronic  catarrh  of  the  pancreatic  duct  is  an  impossibility. 
Its  probability  can  be  reasoned  out,  and  the  treatment  is  fortunately  the 
same  as  that  of  chronic  catarrh  of  the  common  bile-duct. 

Suppurative  Catarrh  of  the  Pancreas. — This  disease  bears  the  same 
relation  to  catarrh  of  the  pancreas  as  does  suppurative  cholangitis  to 
simple  catarrhal  jaundice.  Suppurative  cholangitis  and  suppurative 
catarrh  of  the  pancreas  are  usually  associated. 

Etiology.- — The  usual  cause  of  this  disease  are  gall-stones.  One  can 
explain  that  the  same  cause  may  produce  in  one  case  a  simple  catarrh 
and  in  another  suppuration,  on  the  ground  that  in  suppurative  cases 
there  must  be  a  high  grade  of  infection  with  a  lowered  resistance  on  the 
part  of  the  patient. 

Abscesses  of  the  liver,  gall-bladder,  and  pancreas  are  usually  present. 

Symptoms. — In  the  milder  cases  the  symptoms  are  septicemic,  in 
some  those  of  a  local  abscess  of  the  pancreas,  and  in  the  more  severe  cases 
they  are  pyemic. 

The  preliminary  history  is  one  of  attacks  of  gall-stones  with  sub- 
sequent jaundice,  enlarged  liver,  tenderness  and  pain  in  the  epigastrium 
and  right  hypochondrium,  muscular  rigidity,  frequently  a  mass  in  these 
regions,  irregular  septic  temperature,  chills,  sweating,  leukocytosis,  and 
increased  polynuclears.  Cammidge  found  his  urine  reaction  in  one  of 
these  cases  of  septicemic  type. 

Occasionally,  suppurative  catarrh  of  the  pancreas  may  assume  a 
subacute  form  and  end  in  a  single  pancreatic  abscess  with  the  symptoms 
associated  therewith.  Even  after  drainage  of  simple  abscess  of  the  pan- 
creas, interstitial  pancreatitis  may  occur  and  ultimately  lead  to  the 
death  of  the  patient. 


CHAPTER  XLIII 

ACUTE  PANCREATITIS— CHRONIC  PANCREATITIS 

ACUTE  PANCREATITIS 

The  best  classification  of  acute  inflammation  of  the  pancreas  has  been 
made  by  Fitz:^ 

1.  Hemorrhagic  pancreatitis,  or  hemorrhagic  necrosis  of  the  pan- 
creas (Opie). 

2.  Gangrenous  pancreatitis. 

3.  Suppurative  pancreatitis. 

Gangrenous  pancreatitis,  though  due  to  other  conditions,  is  usually 
the  result  of  hemorrhagic  pancreatitis,  and  in  about  50  per  cent,  of  cases 
recorded  there  is  evidence  of  previous  hemorrhage  in  the  gland.  The 
symptoms  of  the  two  conditions  resemble  each  other,  but  with  gangrenous 
inflammation  the  disease  is  of  longer  duration.  Disseminated  fat  necrosis 
is  present  with  both  the  hemorrhagic  and  gangrenous  types.  Suppurative 
pancreatitis  results  from  hemorrhagic  necrosis  of  the  pancreas,  necrqtic 
tissue  being  particularly  susceptible  to  bacterial  infection.  Pancreatic 
abscess  also  occurs  in  association  with  cholelithiasis  through  ascending 
infection  from  the  intestinal  tract,  or  from  suppurative  cholangitis, 
carcinoma,  compressing  the  pancreatic  duct,  pancreatic  calculi,  perforating 
ulcer  in  an  adjacent  organ,  and  traumatism. 

Fat  necrosis  is  uncommon  with  suppurative  inflammation  of  the  pancreas 
It  is  interesting  to  note  that  an  acute  interstitial  inflammation  of  the 
pancreas  without  suppuration  (acute  interstitial  pancreatitis)  may  oc- 
casionally occur. 

Acute  Hemorrhagic  Pancreatitis 

{Synonyms. — Hemorrhagic  Necrosis  of  the  Pancreas — Opie) 

This  lesion  has  really  not  the  characteristics  of  an  inflammatory 
process.  There  is  a  primary  necrosis  of  the  parenchyma  of  the  pancreas, 
and  the  only  inflammatory  changes  which  occur  are  at  the  margin  of  the 
necrotic  tissue.  It  should  properly  be  called  "hemorrhagic  necrosis  of 
the  pancreas."  Fat  necrosis  which  accompanies  it  has  been  demonstrated 
as  due  to  the  fat-splitting  enzyme  of  the  pancreatic  juice. 

Pancreatic  Hemorrhage. — Hemorrhage  into  the  substance  of  the 
pancreas  may  be  due  to  a  variety  of  causes.  It  may  accompany  tumors  or 
may  occur  in  pancreatic  cysts,  or  with  purpura,  eclampsia,  and  the  acute 
infectious  diseases.  Such  cases  have  nothing  in  common  with  hemorrhagic 
pancreatic  necrosis. 

Experimental  Hemorrhagic  Necrosis  of  the  Pancreas. — Hemor- 
rhagic pancreatitis  has  been  experimentally  produced  on  dogs  by  the 

'  Acute  Pancreatitis,  Med.  Rec,  xxxv,  197,  225,  253,  1889. 
1008 


Fig.  417. — Pancreas  and  adjacent  tissues  from  a  case  of  acute  hemorrhagic  pan- 
creatitis with  fat  necrosis  (St.  Bartholomew's  Hospital  Museumj. 


ACUTE    PANCREATITIS CHRONIC   PANCREATITIS  lOOQ 

injection  of  various  substances  into  the  duct  of  Wirsung,  such  as  the 
deliquescent  chlorid  of  zinc,  artificial  gastric  juice,  papain,  the  diphtheria 
toxin,  hydrochloric  acid,  nitric  and  chromic  acid,^  suspensions  of  bacteria, 
etc.  Bile^  injected  into  the  pancreatic  duct  almost  uniformly  produced 
the  same  results. 

Flexner^  demonstrated  that  the  'hroduction  of  the  lesion  may  be  at- 
tributed to  the  bile  salts. 

Occurrence. — Hemorrhagic  necrosis  of  the  pancreas  is  found  more 
trequently  in  men  than  in  women.  Peiser^  tabulated  121  cases  of  hemor- 
rhagic and  gangrenous  pancreatitis,  of  which  79  occurred  in  men  and  42 
in  women. 

Korte^  collected  37  cases  of  the  hemorrhagic  type  in  males  and  4 
in  females.  In  cases  with  gangrenous  pancreatitis,  21  were  in  males  and 
19  in  females.  Individuals  who  are  apparently  in  good  health  are  not 
infrequently  attacked,  and  fat  patients  are  believed  to  be  particularly 
susceptible. 

Age. — Hemorrhagic  necrosis  of  the  pancreas  and  gangrenous  pan- 
creatitis occur  usually  between  twenty  and  sixty  years  of  age. 

Etiology. — Bacterial  Infection. — Opie^  holds  that  no  relation  between 
hemorrhagic  necrosis  of  the  pancreas  and  bacterial  invasion  has  been 
demonstrated.  Welch"  believes  that  the  organisms  penetrate  the  tissue 
subsequent  to  the  production  of  the  lesion. 

Various  investigators  have  found  the  colon  bacillus,  the  pneumo- 
coccus,  streptococci,  staphylococci  and  other  bacteria  in  acute  hemor- 
rhagic pancreatitis.  Most  agree  that,  as  the  findings  are  inconstant 
and  as  the  necrotic  parenchyma  may  contain  no  microorganisms  they 
are  secondary  invaders  of  the  injured  tissue.  In  view  of  gall-bladder 
infection  produced  by  the  colon  bacillus,  the  author  believes  that  in  some 
instances  the  colon  bacillus  may,  in  part,  be  responsible  for  this  type  of 
acute  pancreatitis.  It  has  been  recently  demonstrated  that  certain 
living  pathogenic  organisms,  especially  of  the  typhoid  and  B.  coli  group, 
are  capable  of  activating  the  proteolytic  pancreatic  enzyme  and  the 
autogestive  action  of  the  enzymes  or  damaged  tissue  is  a  factor.  It  is 
further  interesting  to  note  that  in  an  autopsy  of  one  of  Robson's*  cases, 
performed  three  hours  after  death,  subsequent  to  operation  for  acute 
hemorrhagic  pancreatitis,  blood-cultures  contained  the  bacillus  coli 
communis,  as  did  also  the  pancreas. 

Cholelithiasis. — There  is  a  close  relationship  between  cholelithiasis 
and  acute  pancreatitis.  Egdahl  has  found  that  out  of  105  cases  of 
acute  pancreatitis,  cholelithiasis  was  present  in  42  per  cent.  This  is 
probably  a  minimum  percentage.  The  calculus  is  sufficiently  large  to 
occlude  the  opening  of  the  ampulla  of  Vater  into  the  duodenum,  and  yet 
so  small  that  it  will  not  fill  up  the  ampulla  and  will  not  obstruct  the  orifices 

^  Contributions  to  the  Science  of  Medicine,  Johns  Hopkins  Hosp.  Rep.,  1900,  ix,  793. 
*Opie,  Bull,  of  Johns  Hopkins  Hosp.,  1901,  xii,  182. 
'Jour,  of  Exper.  Med.,  1906,  viii,  167. 

*  Deutsche  Zeit.  f.  Chir.,  1902,  Ixv,  302. 

'  Chirurg.  Krankheit,  des  Pancreas,  Deutsche  Chirurg.,  Stuttgart,  1898. 

*  Disease  of  the  Pancreas. 
'Med.  News,  1891,  lix,  669. 

8  The  Pancreas  (Robson  and  Cammidge),  p.  392. 
64 


lOIO 


DISEASES    OF   THE    STOMACH   AND    INTESTINES 


of  the  common  bile-duct  and  of  the  duct  of  Wirsung.  These  two  ducts  are 
converetd  into  a  continuous  closed  channel,  and  the  bile  entering  the 
pancreas  through  its  duct  produces  a  hemorrhagic  necrosis  of  the  gland. 
In  only  a  little  more  than  three  out  of  ten  persons  is  the  size  of  the  diver- 
ticulum of  Vater  such  that  the  stone  will  block  the  opening  into  the 
duodenum  and  yet  not  obstruct  the  duct  openings.  In  i  out  of  lo  cases 
the  bile-duct  joins  the  smaller  pancreatic  duct,  and,  furthermore,  in  some 
■  cases  the  duct  of  Santorini  is  the  chief  duct  of  the  pancreas.  In  other  cases 
the  common  duct  and  duct  of  Wirsung  enter  the  bowel  separately.  These 
facts  explain  the  comparative  rarity  of  hemorrhagic  necrosis  of  the  pan- 
creas when  compared  with  the  frequency  of  cholelithiasis. 

Opie  reports  eight  cases  of  hemorrhagic  necrosis  of  the  pancreas,  in 
which  gall-stones  were  present  in  five. 


Fig.  418. — Areas  of  fat  necrosis  in  the  mesenteric  and  omental  fat  and  in  the  abdominal 
wall  in  a  case  of  acute  hemorrhagic  pancreatitis  (Fison). 


Penetration  of  the  Duodenal  Contents  into  the  Pancreatic  Ducts. — In 
about  one  out  of  ten  persons  the  duct  of  Santorini  is  the  larger,  and  is 
the  chief  outlet  of  the  gland.  Probably  a  duct  of  this  type  can  be  the 
port  of  entry  of  the  duodenal  contents. 

Catarrhal  duodenitis,  which  preponderates  in  males,  may  pass  by 
regurgitation  directly  into  the  pancreatic  duct.  It  might  render  the 
orifice  of  the  duct  larger  and  less  competent  to  assert  the  valvular  action 
and  might  be  a  factor  in  producing  acute  pancreatitis. 

The  Lymphatics. — The  lymphatic  system  of  the  gall-bladder  directly 
anastomoses  with  that  of  the  pancreas,  and  may  therefore  be  a  source  of 
infection  in  the  production  of  acute  pancreatitis.     Deaver^  holds  that  the 

1  Journal  A.  M.  A.,  Jan.  4,  1913. 


ACUTE    PANCREATITIS — CHRONIC   PANCREATITIS 


lOII 


lymphatics  may  carry  the  infection  and  reports  two  cases  of  acute  appen- 
dicitis followed  by  infection  of  the  pancreas. 

Traumatic  Necrosis. — A  blow,  an  injury  to  the  abdomen  in  the  epi- 
gastric region,  or  a  stab-wound  may  produce  hemorrhage  into  the  pan- 
creas. Crushing  of  the  gland,  associated  with  occlusion  of  the  vessels 
(venous  thrombosis),  together  with  an  escape  of  the  pancreatic  juice  into  the 
damaged  area,  may  be  subsequently  followed  by  hemorrhagic  necrosis. 

Alcoholism  and  diabetes  have  by  some  been  considered  factors  in 
the  production  of  this  type  of  acute  pancreatitis. 

Parturition  has  been  mentioned  as  a  cause,  the  pancreas  being  affected 
in  a  similar  way  as  the  kidneys  and  liver  by  the  toxemias  of  pregnancy. 


Fig.  419. — Hemorrhagic  necrosis  of  the  pancreas,  showing  abrupt  transition  from 
normal  to  necrotic  tissue.  At  the  margin  of  the  living  tissue  are  red  blood-corpuscles, 
leukocytes,  and  fibrin  (Opie,  "Diseases  of  the  Pancreas"). 


The  theory  has  been  advanced  that  the  pancreatic  necrosis  may  result 
from  embolism  of  the  giant  cells  of  the  placenta. 

Undoubtedly  the  major  number  of  cases  of  hemorrhagic  necrosis  of 
the  pancreas  can  he  imputed  to  a  gall-stone  impacted  in  the  mouth  of  the 
ampulla  of  Vater. 

Pathology. — The  pancreas  is  enlarged,  firm,  and  generally  covered 
by  clotted,  black-red  blood  (Fig.  417).  There  is  blood-stained  fluid 
in  the  lesser  peritoneal  cavity,  and  frequently  blood  infiltrates  the  tissues 
about  the  pancreas.  Fat  necrosis  always  accompanies  it  (Fig.  418). 
Usually  the  entire  organ  is  not  affected,  and  there  may  be  areas  of  normal 
parenchyma. 

There  is  coagulation  necrosis  in  the  diseased  areas,  involving  the 


IOI2  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

epithelial  cells,  interstitial  tissue,  and  the  blood-vessels.  There  is  an 
abrupt  transition  from  the  necrosed  area  to  living  tissue,  and  there  is  a 
line  of  demarcation,  a  narrow  zone,  which  contains  fragments  of  nuclei, 
red  blood-cells,  polynuclear  leukocytes,  and  fibrin  (Fig.  419). 

Acute  inflammation  is  not  always  present.  There  is  hyaline  thrombo- 
sis of  the  capillaries  within  the  tissue  which  is  in  contact  with  the  necrotic 
area.  In  some  cases  hemorrhage  may  be  a  slight  feature  and  necrosis 
the  chief  lesion,  with  a  few  hemorrhagic  areas. 

Complete  recovery  may  occur,  and  the  necrotic  area  become  absorbed 
and  replaced  by  fibrous  tissue. 

After  healing  of  the  pancreatic  lesion,  the  lesser  peritoneal  cavity 
may  still  contain  opaque  fluid  and  necrotic  particles,  and  the  pancreas 
be  covered  by  black,  altered  blood. 

As  gangrenous  pancreatitis  is  a  progressive  stage  of  the  acute  hemor- 
rhagic type,  it  will  be  next  described,  and  the  symptoms  of  both  conditions 
will  be  given  later. 

Gangrenous   Pancreatitis 

Stage  of  Gangrene. — Etiology. — This  condition  is  usually  a  sequel 
of  hemorrhagic  necrosis  of  the  pancreas  should  the  patient  survive  a  sufficient 
period  of  time.  Perforating  ulcer  of  the  stomach,  intestines,  or  biliary 
tract,  or  even  extension  of  a  cholangitis  through  the  pancreatic  duct, 
may  be  causes.  Traumatism  may  first  produce  a  hemorrhagic  necrosis  of 
the  pancreas  with  subsequent  gangrene. 

Pathology. — The  pancreas  is  usually  swollen,  dark  red,  or  red-gray, 
or  slate  colored,  generally  foul  smelhng,  and  is  often  surrounded  by  a  thin 
greenish  or  dark-colored  purulent  fluid.  It  may  lie  free  in  the  cavity  of 
the  omentum,  which  last  is  distended  with  ill-smelling  bloody  or  blackish 
fluid. 

In  some  cases  in  about  a  week  or  ten  days  the  pancreas  may  be  dry, 
firm,  and  of  dark-brown  color,  covered  by  altered  blood.  In  the  paren- 
chyma of  the  gland  yellow  spots  of  softening  may  alternate  with  areas  of 
hemorrhage. 

In  others,  in  about  two  weeks  the  pancreas  may  appear  a  black,  soft, 
friable  mass,  and  the  cavity  of  the  lesser  omentum  contain  chocolate- 
colored  fluid  with  blackish  clots. 

The  gangrenous  condition  of  the  gland  is  produced  by  the  invasion 
of  bacteria,  which  produce  these  changes  in  a  necrotic  gland  containing 
extravasation  of  blood. 

Suppuration  with  or  without  perforation  of  the  gastro-intestinal 
tract  is  a  secondary  condition.  The  microscopic  appearance  of  gangrene 
is  quite  typic.     Disseminated  fat  necrosis  is  present. 

Accumulation  of  Fluid  in  the  Lesser  Peritoneal  Cavity. — With  these 
types  of  acute  pancreatitis  there  is  accumulation  of  fluid  in  the  lesser 
peritoneal  cavity.  The  foramen  of  Winslow  is  closed  by  adhesions. 
The  fluid  usually  contains  the  products  of  pancreatic  secretion.  The 
contents  may  at  first  be  sterile,  but  later  become  infected  from  the  gangren- 
ous pancreas.  The  bacillus  coli,  bacillus  lactis  aerogenes,  bacillus  proteus 
vulgaris,  and  streptococcus  pyogenes  have  been  found  in  this  sac. 


ACUTE    PANCREATITIS — CHRONIC    PANCREATITIS  IO13 

An  abscess  may  form,  the  wall  of  which  is  blackish  or  gray,  and 
consists  chiefly  of  necrotic  fat.  The  contained  fluid  may  be  brown  or 
gray  in  color,  and  contain  soft,  greasy,  necrotic  material.  Through 
erosion  the  abdominal  wall  in  the  left  lumbar  region  may  be  perforated, 
or  perforation  into  the  general  peritoneal  cavity  may  occur.  A  sub- 
diaphragmatic abscess  may  form,  and  the  diaphragm  may  be  perforated 
with  a  resulting  empyema.  Perforation  of  the  stomach,  duodenum, 
or  transverse  colon  may  take  place,  and  the  discharge  of  necrotic  pan- 
creatic tissue  from  the  bowel  has  been  recorded. 

Symptoms  of  Acute  Pancreatitis  (Hemorrhagic  and  Gangrenous) 

Symptoms  of  Hemorrhagic  Necrosis. — The  patient  may  have  been 

previously  healthy  or  a  sufferer  from  occasional  attacks  of  indigestion. 
In  some  there  may  be  a  history  of  gall-stone  attack.  Suddenly  there  is 
an  intense  pain  in  the  upper  abdomen,  the  epigastric  region,  followed 
by  vomiting,  more  or  less  obstinate  in  character,  and  severe  collapse, 
which  has  in  a  few  hours  even  caused  death  in  some  cases  reported. 
The  pain,  which  is  very  intense,  never  wholly  subsides,  and  is  paroxysmal 
and  increases  on  movement.  If  the  condition  persists  for  a  longer 
period,  in  the  course  of  twenty-four  hours  there  is  an  epigastric  swelling, 
tympanitic  or  resistant,  with  tenderness  on  pressure,  which  is  present  from 
above  the  umbilicus  to  the  ensiform  process  and  over  the  pancreas.  The 
tenderness  may  be  most  marked  at  Robson's  point.  Obstinate  consti- 
pation occurs,  though  the  obstruction  is  not  absolute,  as  flatus  occasion- 
ally passes  and  a  large  enema  may  secure  a  movement.  A  normal 
or,  usually,  subnormal  temperature  is  present  in  the  very  acute  cases. 
If  the  case  survives  several  days  there  may  be  irregular  temperature, 
or  occasionally  it  may  be  high.  The  pulse  is  rapid  and  small  and  cyanosis 
may  result,  both  of  the  face  and  abdominal  wall  particularly  (Halsted). 
The  aspect  is  "anxious  and  the  face  pinched.  An  epigastric  peritonitis 
is  present  at  first,  which  later  may  become  general,  and  general  disten- 
tion occur.  Tender  spots  are  also  often  present  throughout  the  abdo- 
men. They  are  believed  to  lie  over  the  areas  of  fat  necrosis.  Jaun- 
dice may  be  present,  at  first  slight,  which  may  later  deepen.  The  vomitus 
may  consist,  first,  of  food;  later,  of  bile,  and,  finally,  of  black  altered 
blood.  Hemorrhage  may  also  occur  from  the  other  mucous  surfaces, 
the  intestines,  subcutaneously,  and  into  the  skin.  Death  usually  occurs 
on  the  second  to  fifth  day,  though  a  fatal  issue  may  take  place  within  a 
few  hours.  Delirium  may  occur  before  death.  This  condition  may  be 
mistaken  for  intestinal  obstruction,  but  stercoraceous  vomiting  and  visible 
peristalsis  of  the  intestines  are  absent,  which  occur  in  the  latter.  On 
laparotomy,  areas  of  fat  necrosis  are  visible,  which  are  at  once  suggestive 
of  the  condition. 

Subacute  Pancreatitis. — The  writer  has  recently  seen  a  case  in  which 
there  was  an  acute  attack  of  pain,  apparently  from  a  gall-stone ;  tenderness 
over  the  pancreas  and  common  duct;  vomiting  of  blood  and  passage  of 
blood  in  the  stools;  no  jaundice  and  no  shock  of  marked  degree.  Recovery 
ensued.     The  stone  evidently  escaped  into  the  gut. 


IOI4  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

symptoms  of  Gangrene  of  the  Pancreas. — With  this  condition  the 
violent  symptoms  of  an  acute  hemorrhagic  pancreatitis,  which  may 
precede  it,  may  diminish  in  their  severity,  or  the  symptoms  of  the  onset 
may  be  less  severe  in  character.  The  patient  survives  the  more  acute 
attack  and  the  condition  is  more  chronic.  Opportunity  is  given  for 
bacterial  invasion  and  subsequent  gangrene.  The  pain  is  localized  in 
the  epigastric  region  and  vomiting  may  occur  at  intervals.  Symptoms 
pointing  to  suppuration  eventually  give  evidence  that  infection  has 
occurred.  There  are  frequently  an  irregular  temperature  and  chills. 
Diarrhea  may  later  be  present.  An  ill-defined  tumor  may  at  times  be 
felt  above  the  umbilicus,  due  to  accumulation  of  fluid  in  the  lesser  peri- 
toneal cavity,  or  to  hemorrhagic  purulent  fluid  about  the  pancreas.  The 
mass  is  generally  situated  in  the  epigastrium,  and  extends  toward  the 
spleen.  Inflation  of  the  stomach  and  colon  may  aid  in  locating  its  posi- 
tion. The  stomach  separates  the  tumor  from  the  liver,  and,  when  inflated, 
covers  it.  At  times  erosion  of  tissue  over  the  left  kidney  occurs,  and  there 
may  be  a  swelling  below  the  left  costal  margin  as  far  as  the  iliac  crest. 

The  gangrenous  type  of  pancreatitis  may  be  prolonged  for  several 
weeks  or  longer.  Considerable  loss  of  weight  may  occur  in  these  cases 
when  prolonged. 

In  both  these  types  of  acute  pancreatitis,  digestive  disturbances, 
such  as  have  been  described  under  the  General  Symptoms  of  Diseases  of 
the  Pancreas,  may  occur.  Seldom  is  there  such  destruction  of  the 
pancreas  that  its  functional  activity  is  entirely  destroyed.  Sugar  is 
rarely  present;  fatty  stools  are  rare. 

Leukoc3rtosis.— Leukocytosis  may  be  present  during  the  first  few 
days  of  the  attack  of  hemorrhagic  necrosis  of  the  pancreas.  It  is  not 
always  present,  however.  With  gangrenous  pancreatitis,  leukocytosis 
may  vary  from  15,000  to  40,000.  It  may  diminish,  and  there  may  even 
be  leukopenia  before  death.  Increased  polynuclears  occur  with  leukocy- 
tosis.    Blood  clotting  is  delayed. 

Diagnosis  and  Differential  Diagnosis. — The  anamnesis,  the  symp- 
toms of  acute  epigastric  peritonitis,  pain,  vomiting  and  collapse,  and  the 
fulminating  character  of  the  attack  are  at  once  suggestive.  The  writer 
believes  that  determination  of  the  pancreatic  functions,  the  Cammidge 
reaction,  etc.,  are  of  no  practical  assistance.  The  condition  is  acute,  and 
radical  procedure  is  indicated,  with  no  delay.  Laparotomy  reveals  fat 
necrosis,  which  is  diagnostic  in  connection  with  the  symptoms. 

With  intestinal  obstruction  there  are  stercoraceous  vomiting  and 
intestinal  paralysis;  no  flatus  is  passed.  With  perforation  of  duodenal 
or  gastric  ulcer  the  history,  gravitation  of  the  contents  toward  the  pelvis 
the  general  peritonitis  and  the  absence  of  liver  dulness  are  serviceable 
data. 

With  phlegmonous  cholecystitis  the  swelling  and  tenderness  usually 
first  lie  below  the  right  costal  margin,  tenderness  is  to  the  right  (over 
Murphy's  point)  i.e.  the  gall-bladder.  Pain  passes  through  to  the  back 
and  right  shoulder.  Determination  of  the  gall-bladder  zone  (Head)  is 
of  service. 

With  appendicitis  epigastric  pain  may  first  be  present,  but  tenderness 


ACUTE    PANCREATITIS — CHRONIC   PANCREATITIS  IOI5 

at  McBurney's  point  and  muscular  rigidity  over  tne  appendix  are  present. 
Head's  zone  for  the  appendix  is  also  diagnostic. 

Treatment. — Collapse  must  receive  treatment  at  once  and  the  acute 
pain  must  be  relieved,  which  is  in  itself  a  serious  factor  in  producing  the 
shock.  Morphin,  }4  to  K  grain  (0.015-0.03),  may  be  given  by  hypo- 
dermic injection,  and  strychnin,  3^0  grain  (0.002),  camphor  oil,  5  grains 
(0.3)  camphor  in  15  minims  d.o)  of  sterile  olive  oil  or  almond  oil,  should 
be  administered.  Hypodermoclysis  may  be  indicated.  Vomiting  should 
be  relieved  by  lavage.  Hot  saline  enemata,  i  pint  to  i  quart  (500-1000 
c.c.)  each,  at  i2o°F.,  may  be  given  for  shock.  A  nutritive  enema  may  be 
added,  and  in  the  latter  20  grains  of  lactate  of  calcium  should  be  given  to 
overcome  the  hemorrhagic  tendency.  Chlorid  or,  preferably,  lactate  of 
calcium,  60  to  90  grains  (i-iM  drams)  daily,  should  be  given  in  divided 
doses,  15  grains  (i.o)  at  a  time,  by  enema,  both  before  and  after  opera- 
tion, in  the  latter  event  for  ten  days.  In  a  recent  case  with  hematemesis 
and  inability  to  retain  the  enema,  10  grains  (0.6)  of  lactate  of  calcium 
were  dissolved  in  5  ounces  of  water  and  i-dram  doses  of  this  solution 
given  by  mouth  every  one-half  to  one-quarter  hour  with  success.  This 
was  repeated  several  times  daily.  Proctoclysis  with  the  addition  of  cal- 
cium lactate  5i  to  the  solution  is  also  valuable.  Human  blood-serum 
20  c.c.  may  also  be  injected  hypodermically,  if  necessary,  to  combat  the 
hemorrhagic  tendency,  or  horse  serum  by  mouth.  Continuous  entero- 
clysis  with  hot  saline  at  i20°F.  will  both  relieve  distention  and  stimulate 
the  patient.  Recourse  to  laparotomy  is  indicated  as  soon  as  the  shock 
is  relieved.  Incision  is  made  in  the  median  line  or  over  the  'most  prom- 
inent part  of  the  tumor,  if  such  can  be  determined.  On  opening  the  ab- 
domen the  presence  of  fat  necrosis  is  at  once  diagnostic  of  pancreatic 
involvement. 

The  cavity  of  the  lesser  peritoneum  is  then  entered  through  the 
gastrocolic  ligament,  and  fluid  and  necrotic  material,  if  present,  are 
evacuated.  The  pancreas  should  also  be  drained.  The  operator  should 
determine  the  condition  of  the  bile-passages,  and  if  the  shock  of  the 
operation  be  not  dangerously  increased  by  further  procedure,  gall-stones, 
if  present,  should  be  removed  from  the  gall-bladder  and  any  impacted 
stone  from  the  common  duct.  If  prolongation  of  the  operation  seem 
inadvisable,  the  gall-bladder  should  be  drained,  and  by  a  subsequent 
operation  the  stones  removed  therefrom  and  the  impacted  stone  cleared 
from  the  ampulla.  Subsequent  to  operation  on  the  pancreas,  during 
the  drainage  period,  severe  hemorrhage  from  the  wound,  due  to  erosion 
of  the  larger  blood-vessels  from  the  glandular  secretion  of  the  pancreas, 
has  been  reported.  Korte  has  seen  some  44  cases  of  hemorrhage  from  this 
cause  and  reports  six  deaths  from  such  occurring  from  eleven  to  thirty- 
four  days  after  operation.  Proctoclysis  subsequent  to  operation  is  of 
value  for  the  sepsis  and  lactate  of  calcium  should  be  continued  to  check 
hemorrhagic  tendency  by  hastening  blood  clotting. 

Supptirative  Pancreatitis 

Pathology. — The  pancreas  is  enlarged.  There  may  be  a  diffuse 
suppurative  process  of  the  gland,  or  multiple  small  abscesses,  in  which 


IOl6  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

the  process  is  more  acute,  or  there  may  be  a  single  abscess  of  the  pancreas 
(subacute  pancreatitis — Robson),  a  less  acute  process,  and  which  may  even 
be  of  considerable  duration.  Rarely,  there  may  be  an  acute  interstitial 
pancreatitis  without  suppuration — an  intermediary  stage. 

Etiology. — Suppurative  pancreatitis  may  be  secondary  to  hemor- 
rhagic necrosis  of  the  pancreas,  or  quite  frequently  result  from  ascending 
infection  of  the  pancreatic  duct.  It  may  occur  in  association  with  chole- 
lithiasis by  occlusion  of  the  duct  of  Wirsung  by  a  calculus  lodged  in  the 
diverticulum  of  Vater.  Suppurative  cholangitis  or  cyst  of  the  pancreas 
may  be  followed  by  suppuration. 

Pancreatic  calculi,  carcinoma  compressing  the  pancreatic  duct, 
carcinoma  of  the  diverticulum  of  Vater,  or  ulceration  of  neighboring  organs 
may  produce  abscess  of  the  pancreas.  Traumatism  and  digestive  dis- 
turbances have  been  considered  factors. 

Bacterial  Infection. — Among  the  microorganisms  isolated  from  abscess 
of  the  pancreas  are  Bacillus  coli,  pyogenic  cocci,  proteus  vulgaris,  and 
diplococcus  lanceolatus.  Colon  bacillus  infection  the  author  believes  to 
be  a  possible  etiologic  factor. 

Fat  necrosis  rarely  accompanies  suppurative  pancreatitis.  » 

Sequelae  of  Suppurative  Pancreatitis. — Infection  of  the  lesser  peritoneal 
cavity  is  frequent.  Perforation  into  the  general  peritoneum  may  result. 
The  abscess  has  ruptured  into  the  stomach,  with  resulting  vomiting  of 
pus,  or  has  perforated  the  bowel,  with  discharge  of  pus  therefrom.  Throm- 
bosis, with  infection  of  the  splenic  and  portal  veins  and  metastatic  abscess 
of  the  liver,  may  occur.  The  pus  may  burrow  into  the  right  loin  and  be 
mistaken  for  a  perirenal  abscess.  It  may  find  its  way  into  the  left  ihac 
region  or  form  a  subphrenic  abscess.  It  may  burrow  between  the  liver 
and  stomach,  or  reach  the  surface  above  or  below  the  latter,  or  pass  into 
either  loin  or  into  the  pelvis,  or  into  the  left  broad  ligament. 

Even  with  proper  drainage,  chronic  interstitial  oancreatitis  may  result, 
from  which  the  patient  may  succumb. 

Sjonptoms  of  Suppurative  Pancreatitis.- — If  this  condition  results 
from  hemorrhagic  necrosis  of  the  pancreas,  cholelithiasis,  pancreatic 
cyst,  or  pancreatic  lithiasis,  its  symptoms  are  modified  by  the  preceding 
condition.  In  about  50  per  cent,  of  the  cases  there  are  first  a  sudden 
onset,  with  intense  epigastric  pain,  vomiting  and  collapse,  the  symptoms 
of  hemorrhagic  pancreatitis,  of  which  suppurative  pancreatitis  may  be  a 
sequel.  The  severity  of  the  symptoms  then  lessens  and  the  course 
becomes  chronic.  In  others  there  may  be  a  more  or  less  sudden  onset 
with  severe  pain,  vomiting,  and  constipation,  but  collapse  is  not  a  marked 
symptom  and,  as  a  rule,  is  absent. 

The  upper  region  of  the  abdomen  in  these  cases  does  not  become 
as  rapidly  distended,  and  vomiting  is  less  severe.  In  others  the  onset 
is  gradual  and  the  symptoms  are  less  severe.  The  abdominal  pain 
may  be  little  more  than  discomfort  and  gastric  disturbances  occur  at 
times.  In  some  cases  a  history  of  intermittent  attacks  of  pain,  at  first 
without  and  later  with  jaundice,  may  be  elicited,  due  to  gall-stones,  and 
in  others,  symptoms  of  infective  cholangitis,  with  rigors,  intermittent 
fever,  and  deepening  of  the  jaundice. 


ACUTE    PANCREATITIS — CHRONIC    PANCREATITIS  IOI7 

Thayer^  reports  a  case  of  jaundice  due  to  pressure  of  a  pancreatic 
abscess  on  the  common  bile-duct  in  which  carcinoma  was  suspected. 

Tenderness  over  the  pancreas  is  usually  well  marked,  and  in  about 
one-fourth  of  the  cases  a  palpable  tumor  can  be  determined.  This 
is  more  frequently  due  to  accumulation  of  inflammatory  products  within 
the  lesser  peritoneal  cavity  than  to  a  palpable  pancreas. 

Constipation  may  be  followed  by  diarrhea,  which  may  be  fetid  in 
character  if  pus  or  blood  are  present  in  the  stools.  Fatty  stools  may 
occasionally  be  observed  or  impaired  absorption  of  fat  may  at  times  be 
determined.  Robson  believes  that  fat  and  undigested  muscle-fibers  are 
usually  present  in  the  stools,  and  Opie,  that  they  rarely  occur.  Glycosuria 
is  rare. 

The  writer  believes  that  fat  in  the  stools  and  glycosuria  are  rare  oc- 
currences. In  the  subacute  or  chronic  type  of  case  the  pulse  is  not  seri- 
ously affected.  In  many  cases  there  is  fever,  reaching  up  to  io5°F., 
with  recurring  chills.  The  morning  temperature  may  be  normal.  Leu- 
kocytosis is  present  and  increased  polynuclears.  There  is  a  gradual 
loss  of  flesh  and  the  patient  becomes  more  feeble.  Albuminuria  is 
quite  frequently  present.  Robson  holds  that  the  Cammidge  reaction  is, 
as  a  rule,  well  marked.  The  author  believes  it  may  be  tried,  but  doubts  its 
diagnostic  value. 

Suppurative  pancreatitis  with  single  abscess  formation  tends  to  take 
a  chronic  course,  from  one  to  even  eleven  months.  With  diffuse  suppura- 
tion, liver  abscess  may  be  associated  and  the  symptoms  may  be  pyemic. 

There  may  be  evidence  of  abscess  formation  in  the  regions  described 
under  Sequelas  of  Suppurative  Pancreatitis. 

Rarely,  there  is  no  elevation  of  temperature,  and  when,  in  addition, 
the  mass  cannot  be  palpated,  pancreatic  abscess  cannot  be  determined. 

Diagnosis. — Early  occurrence  of  fever,  with  chills,  epigastric  tender- 
ness, pain  and  swelling,  and  leukocytosis,  suggests  pancreatic  abscess. 
When  it  follows  hemorrhagic  necrosis  of  the  pancreas  the  diagnosis  is  more 
difficult,  since  when  this  condition  reaches  the  stage  of  gangrene,  abscess 
of  the  lesser  peritoneum  may  also  be  present,  as  it  is  also  in  suppurative 
pancreatitis.  A  chronic  course,  however,  suggests  suppuration.  Fat 
necrosis  is  also  usually  absent. 

Treatment. — During  the  acute  stage  the  treatment  of  vomiting, 
collapse,  and  distention  are  the  same  as  with  the  other  types  of  acute 
pancreatitis  already  described. 

Enemata  of  soapsuds,  with  i  dram  of  spirits  of  turpentine,  or  enteroclysis 

at  120°  F  aid  in  relieving  distention.     Calomel  is  of  value  to  empty  the 

bowel  during  the  constipated  stage,  and  can  be  given  in  a  dose  of  5  grains 

(0.3),  or  it  may  be  administered  in  small  doses  as  an  intestinal  antiseptic, 

in  either  case  to  be  followed  by  a  saline  cathartic.    Lactate  of  calcium, 

60  grains  (4.0),  should  be  given  daily  in  divided  doses  before  and  after 

operation  to  prevent  hemorrhage,  or,  if  such  is  occurring.     The  urine 

should  be  examined  for  colon  bacilli  and  urotropin-  and  benzoate  of  soda, 

80  grains  (5.3)  each,  should  be  given  by  enema  in  divided  doses  daily  if 

such  are  present. 

'  Amer.  Med.,  1902,  341. 

^  Hexamethylenamin  may  be  substituted. 


IOl8  DISEASES'  OF   THE    STOMACH   AND    INTESTINES 

Early  operation  with  drainage  of  the  abscess  is  indicated;  also  the 
removal  of  biliary  or  pancreatic  calculi  if  such  are  present. 

CHRONIC  PANCREATITIS 

In  undertaking  to  give  the  reader  a  clear  and  concise  conception 
of  chronic  interstitial  pancreatitis,  so  that  he  may  readily  be  enabled  to 
diagnose  this  condition,  the  writer,  in  the  present  state  of  our  medical 
knowledge,  is  confronted  by  an  almost  impossible  task.  Though  the 
study  of  this  lesion  or,  rather,  of  one  particular  type  of  it,  has  contributed 
important  facts  to  our  knowledge  of  diabetes  mellitus,  yet  chronic  pan- 
creatitis of  another  anatomic  type,  at  times  difficult  to  diagnose  as  a 
result  of  various  factors,  may  occur.  The  symptoms  appearing  with  the 
primary  disease,  such  as  inflammatory  conditions  of  the  gall-bladder, 
duodenum,  etc.,  which  may  stand  in  a  direct  causative  relation  to  the 
chronic  pancreatitis,  may  greatly  obscure  the  diagnosis.  One  must 
frequently  arrive  at  the  latter  by  the  process  of  exclusion.  It  may 
simulate  biliary,  duodenal  or  gastric  disease  or  chronic  appendicitis  with 
symptoms  referred  to  the  upper  abdomen,  and  differentiation  may  be 
possible  only  at  operation.  Chronic  inflammation  of  the  pancreas  may 
be  present,  and,  on  account  of  anatomic  peculiarities  of  the  gland  found 
in  a  percentage  of  cases,  the  disease  may  become  well  advanced  before 
disturbances  of  the  pancreatic  functions  can  be  determined.  Opie,  in 
fact,  holds  the  view  that  "the  lesion  is  seldom  associated  with  such 
definite  symptoms  as  to  be  recognized  during  life,  and  that,  even  at 
autopsy,  the  condition  is  frequently  overlooked." 

Robson  and  Cammidge,  on  the  contrary,  believe  that  "from  examina- 
tion of  the  patient,  the  history  of  the  case,  and  the  results  of  chemic  and 
microscopic  examination  of  the  excreta,  a  correct  opinion  may  be  formed 
in  a  large  majority  of  instances."  These  represent  extreme  views. 
The  writer  believes  that  in  many  cases  the  diagnosis  of  chronic  pancreatitis 
is  possible,  while  in  other  instances,  especially  in  the  early  cases,  our 
present  medical  knowledge  is  not  sufficiently  advanced  to  permit  accurate 
determination  of  this  lesion.  The  diagnosis  in  a  well  advanced  case  of 
chronic  pancreatitis  is  frequently  not  particularly  difficult. 

Sex. — In  30  of  Opie's^  cases,  17  occurred  in  males  and  13  in  females; 
while  in  Deaver's^  patients,  22  were  males  and  16  females.  Bohm  reports 
65  per  cent,  males  and  35  per  cent,  females.  The  disease,  therefore, 
preponderates  in  the  male  sex. 

The  relation  of  sex  to  chronic  pancreatitis,  as  compared  with  chole- 
lithiasis, is  reversed,  biliary  affections  preponderating  in  the  female. 

Age. — Opie  has  collected  30  cases  from  the  age  of  ten  to  eighty  years. 
Twenty,  or  two-thirds,  occurred  between  forty  and  sixty  years.  These 
included  postmortem  records.  Deaver  reports  34  cases,  in  which  four  were 
under  thirty  years  of  age  and  the  balance  between  thirty  and  sixty  years. 
Two-thirds  of  these  cases  occurred  between  forty  and  sixty  years.  All 
but  one  were  operative. 

^  Disease  pf  the  Pancreas. 

"  Jour.  Amer.  Med.  Assoc,  April  15,  191 1;  ibid.,  July  i,  191 1. 


ACUTE    PANCREATITIS — CHRONIC    PANCREATITIS  lOIQ 

Etiology. — In  about  one-half  to  two-thirds  of  all  cases  of  chronic  pan- 
creatic, cholecystitis  and  cholelithiasis  are  found  to  be  the  exciting  causes. 

Deaver  found  disease  of  the  gall-bladder  or  ducts  in  65  per  cent., 
and  one-half  had  gall-stones  at  operation;  Mayo  found  gall-stones  in  81 
per  cent. ;  Robson,  in  60  per  cent. 

A  large  calculus  in  the  diverticulum  of  Vater  or  in  the  common  duct 
above  its  junction  with  the  pancreatic  duct  may  compress  the  latter  and 
cause  chronic  inflammation  of  the  pancreas.  Bacterial  infection  (ascend- 
ing infection)  of  the  duct  of  Wirsung  is  probably  a  factor,  A  small 
calculus  in  the  orifice  of  the  diverticulum  of  Vater  usually  produces  acute 
pancreatitis.  Flexner  reports  from  his  experiments  that  when  the 
position  of  the  bile  is  modified  by  a  diminution  of  its  salts  or  by  an  increase 
of  colloid  material,  its  entrance  into  the  pancreatic  duct  is  likely  to  set 
up  a  chronic  pancreatitis,  while  fresh  unaltered  bile  sets  up  acute  changes. 
Small  stones  sometimes  cause  chronic  pancreatitis,  so  that  modified  bile 
in  these  cases  has  probably  been  diverted  into  the  duct. 

Wm.  J.  Mayo^  finds  that  cholecystitis  without  stones  or  jaundice  is 
responsible  for  chronic  pancreatitis  and  advises  removal  of  the  gall- 
bladder for  this  condition. 

Malignant  Growths. — A  growth  compressing  or  invading  the  pancreas 
may  produce  chronic  pancreatitis;  it  may  either  compress  the  duct  of 
Wirsung  or  obstruct  the  ampulla  or  papilla,  interfering  with  the  flow  of 
pancreatic  secretion.  Infection  from  an  ulcerated  surface  may  be  a 
factor.  The  pancreas  may  be  invaded  by  a  carcinoma  of  the  stomach, 
with  resulting  local  or  diffuse  interstitial  inflammation. 

Impacted  pancreatic  calculus,  stenosis  of  the  duodenal  orifice  of  the 
gland  following  ulceration,  and  hydatid  membrane  obstructing  the  opening 
are  reported  as  causes. 

Ascending  Infection  from  the  Duodenum. — Chronic  pancreatitis  may 
result  from  extension  of  a  duodenal  catarrh  into  the  pancreatic  duct. 
Associated  bacterial  infection  is  a  factor  even  when  the  ducts  are  blocked 
by  calculi. 

In  the  latter  event,  bacteria  may  enter  along  the  walls  of  the  inflamed 
duct  through  the  lymphatics  or  blood-stream. 

Infectious  Diseases  and  from  Adjacent  Orgaw^.— Chronic  pancreatitis 
may  occasionally  occur  as  a  sequel  to  typhoid  fever,  mumps,  influenza, 
and  other  zymotic  diseases.  Extension  of  the  inflammatory  process  from 
an  adjacent  organ,  as  in  a  case  of  gastric  ulcer  or  carcinoma  of  the  pylorus, 
may  produce  it.  Among  other  causes  are  arteriosclerosis  and  chronic 
passive  congestion  of  the  pancreas,  due  to  chronic  diseases  of  the  heart, 
lungs,  and  liver. 

The  action  of  toxic  substances  in  the  blood  may  produce  a  chronic 
pancreatitis,  notably  tuberculosis,  syphilis,  and  alcohol. 

Chronic  pancreatitis  is  quite  frequently  associated  with  cirrhosis  of 
the  liver.  In  30  of  Opie's  cases  of  chronic  pancreatitis,  cirrhosis  of  the 
liver  was  present  in  eight. 

Lefas^  and  Opie^  find  that  chronic  pancreatitis  may  accompany  either 

1  Amer.  Jour.  Med.  Science,  April,  1914. 

2  Arch.  gen.  de.  Med.,  1900,  U.  S.,  iii,  539. 
'  Disease  of  the  Pancreas. 


I020 


DISEASES    OF    THE    STOMACH    AND    INTESTINES 


the  atrophic  form  of  cirrhosis  of  the  Hver  (Laennec's)  or  the  hypertrophic 
form.  In  the  former  case  the  type  of  pancreatitis  is  intralobular  (inter- 
acinar),  and  the  weight  of  that  organ  is  increased,  while  in  the  latter  case 
the  interlobular  type  occurs,  and  there  is  no  increase  in  the  volume  of 
the  pancreas.  Cirrhosis  of  the  liver  and  interacinar  pancreatitis  are 
associated  with  diabetes  mellitus  with  hemachromatosis. 

The  writer  has  recently  reported  a  case  of  undoubted  chronic  pan- 
creatitis with  marked  colon  b.  bacilluria.  He  believes  the  colon  bacillus 
responsible  in  some  cases.     This  patient  had  steatorrhea. 

Pathology. — There  are  two  types,  of  chronic  interstitial  inflammation 
of  the  pancreas — the  interlobular  and  the  interacinar. 

Chronic  Interlobular  Pancreatitis. — Etiology. — This  type  is  most  fre- 
quently due  to  obstruction  of  the  pancreatic  duct  or  to  ascending  infection 
along  the  duct. 


Fig.  420. — Chronic  interstitial  pancreatitis  of  the  interlobular  variety  (Santos). 


The  interlobular  tissue  is  the  site  of  the  chief  change,  and  the  gland 
is  dense,  hard,  and  the  surface  is  nodular  or  granular.  The  tissue  on 
section  is  compact  and  homogeneous,  the  areolar  tissue  being  replaced 
by  scar-like  bands.  Occasionally  the  gross  appearance  may  be  little 
altered,  so  that  the  lesion  can  only  be  recognized  under  the  microscope. 
Considerable  fat  may  infiltrate  the  newly  formed  tissue,  and  small  foci 
of  fat  necrosis  may  be  present. 

Coarse  glands  of  fibrous  tissue  separate  the  lobules  of  the  parenchyma^ 
and  lymphoid  cells,  plasma  cells,  and  eosinophiles  are  present  in  the 
interstitial  tissue.  The  chief  increase  of  fibrous  tissue  is  between  the 
lobules.  Acini,  with  atrophied  nuclei  and  dilated  laminae,  are  at  times 
separated  by  new  tissue.  The  islands  of  Langerhans  are  unaltered  (Fig. 
420). 

When  the  case  is  far  advanced,  the  pancreas  may  become  densely 


ACUTE    PANCREATITIS — CHRONIC   PANCREATITIS  I02I 

sclerotic,  fibrous  tissue  replacing  the  gland  tissue  to  a  great  extent, 
there  remaining  small  masses  of  the  parenchyma  embedded  in  fibrous 
tissue.  The  islands  of  Langerhans  are  unchanged,  being  frequently  the 
only  remains  of  the  parenchyma,  lying  amid  sclerotic  bands.  They  are 
resistant  to  the  sclerotic  process,  and  only  suffer  in  extreme  cases  when 
the  acini  are  nearly  completely  replaced  hy  fibrous  tissue. 

Chronic  Interacinar  Pancreatitis. — With  this  type  of  pancreatitis  there 
is  a  diffuse  increase  of  the  interacinar  stroma,  and  the  organ  is  tougfi, 
rather  than  hard,  and  the  surface  is  smooth.  It  is  characterized  by  newly 
formed  tissue  within  the  lobules  (intralobular)  (Fig.  421). 

The  lesion  is  irregular  in  its  distribution.  There  is  thickening  at  one 
point  of  the  connective-tissue  network  supporting  the  acini,  while  in  other 


Fig.  421.^ — Chronic  interstitial  pancreatitis  of  interacinar  type  showing  the  invasion 
of  Langerhans  by  the  inflammatory  process  (Opie). 

regions  there  are  compact  bands  or  masses  of  stroma.  The  interlobular 
tissue  is  not  entirely  unaffected,  but  its  proliferation  is  not  constant  and  is 
inconspicuous.  The  lobules  are  not  accentuated,  but  the  interlobular 
boundaries  are  obscured  by  strands  of  new  tissue.  The  new  growth 
invades  the  islands  of  Langerhans. 

They  are  almost  constantly  surrounded  by  fibrous  tissue,  forming  a 
capsule  which  separates  them  from  the  adjacent  acini,  which  last  are 
separated  from  each  other.  There  is  proliferation  of  interstitial  tissue 
about  the  capillaries  of  the  islands,  which  forms  coarse  strands  between 
the  columns  of  cells.  In  the  early  stages  there  is  an  accumulation  of 
lymphoid  cells  in  and  about  the  islands.  In  some  instances  this  type  of 
inflammation  (sclerosis)  is  almost  entirely  limited  to  the  islands  of 
Langerhans. 


I02  2  DISEASES    OF   THE    STOMACH   AND    INTESTINES 

Interacinar  pancreatitis  is  much  less  common  than  the  intralobular 
form,  and  the  former  condition  has  direct  association  with  diabetes  mellitus. 

Lipomatosis  (infiltration  with  adipose  tissue)  occurs  in  association 
with  chronic  interstitial  inflammation  of  the  pancreas  in  both  types  of 
this  lesion. 

S3nnptoms. — In  many  cases  the  diagnosis  of  chronic  pancreatitis  is 
impossible,  particularly  in  the  early  stages  of  the  interlobular  type  of  the 
disease,  and  at  times,  even  when  the  lesion  is  fairly  well  marked,  sufficient 
of  the  normal  parenchyma  remains  for  the  organ  to  partially  perform  its 
functions. 

The  anamnesis  is  often  of  considerable  value,  in  arriving  at  a  definite 
conclusion.  A  history  of  bad  habits  of  eating  or  drinking,  with  resulting 
chronic  inflammatory  conditions  of  the  stomach  and  duodenum,  or  of 
infectious  diseases,  which  are  likely  to  be  followed  by  disease  of  the  biliary 
passages,  or  a  history  pointing  to  attacks  of  gall-stones  or  impacted  gall- 
stone with  cholangitis  and  intermittent  fever,  would  be  suggestive  of  the 
probability  of  secondary  involvement  of  the  pancreas.  In  some  cases 
chronic  pancreatitis  may  exactly  simulate  this  last  condition,  and  the  writer 
will  describe  a  case  simulating  duodenal  ulcer  with  pyloric  stenosis.  On 
the  other  hand,  when  with  a  history  as  described  above  there  follow, 
progressive  loss  of  weight,  jaundice  which  tends  to  persist,  though  at  times 
it  may  intermit,  disturbances  of  the  digestive  functions,  pain  or  aching  in 
the  epigastrium,  or  a  sense  of  discomfort,  an  excess  of  unabsorbed  fecal 
fat,  or  an  undtie  amount  of  unsplit  fat  in  the  feces,  epigastric  tenderness, 
and  fulness  in  this  region  with  or  without  a  swelling  of  the  pancreas,  a 
diagnosis  of  chronic  pancreatitis  can  be  made  with  certainty.  The 
Cammidge  reaction,  the  writer  believes,  is  not  always  present,  and  he, 
at  present  writing,  is  very  doubtful  as  to  its  value.  Jaundice,  however, 
is  not  always  present. 

Chronic  Pancreatitis  Simulating  Gastric  or  Duodenal  Ulcer  with 
Pyloric  Stenosis.— Recently  the  writer  examined  a  patient,  a  girl  of 
twenty-six  years,  with  a  history  of  gastric  disturbances  of  three  years' 
duration;  pain  after  eating,  more  frequently  after  several  hours;  occa- 
sional vomiting;  history  of  apparent  occasional  attacks  of  coffee-ground 
hematemesis.  Patient  anemic.  Total  acidity,  60-I-;  free  HCl,  30-I-; 
combined  HCl,  2^-\-.  No  pus,  no  occult  blood  detected  in  gastric  con- 
tents. Stool  showed  some  disturbance  of  intestinal  digestion,  but 
nothing  typical  of  chronic  pancreatitis.  There  was  local  tenderness  in 
one  point  in  the  epigastrium.  Stomach  lies  with  lower  border  at 
umbilicus.  The  writer  believed  the  case  one  of  pyloric  obstruction 
(partial),  due  probably  to  duodenal  ulcer.  Operation  by  John  Connors 
disclosed  a  dilated  stomach;  no  ulcer  of  stomach  or  duodenum;  a  partial 
stenosis  of  the  duodenum  from  enlarged  head  of  the  pancreas;  the  entire 
pancreas  showed  evidences  of  chronic  pancreatitis,  no  gall-stones  in 
common  duct  or  gall-bladder,  but  the  latter  was  filled  with  very  thick 
inspissated  bile.  The  gall-bladder  was  drained.  At  present  writing, 
several  weeks  since  operation,  there  are  no  gastric  disturbances.  Whether 
the  head  of  the  pancreas  will  become  smaller,  with  no  subsequent  symp- 
toms, or  whether  the  condition  later  progresses,  time  alone  will  determine. 


ACUTE   PANCREATITIS — CHRONIC   PANCREATITIS  IO23 

On  the  other  hand,  in  Fig.  422  is  demonstrated  an  early  case  of  evi- 
dently commencing  chronic  pancreatitis  due  to  gall-stones.  The  patient 
is  suffering  from  chronic  toxemia  (biliary) — though  no  jaundice  at  the 
present  time.  She  has  hyperchlorhydria  of  rather  mild  type  with  gastric 
symptoms.  The  gall-bladder  and  appendix  are  both  sensitive  to  pressure. 
There  are  a  large  number  of  fatty  acid  crystals  in  the  stool  and  incomplete 
absorption  of  the  products  of  fat  digestion.  The  urine  shows  a  trace  of 
bile,  indicanuria,  a  trace  of  albumin  and  a  few  casts.  Operation  to  be 
immediate. 

As  Deaver  justly  remarks,  the  diagnosis  is  most  frequently  made  in 
those  who  are  driven  to  surgical  intervention  on  account  of  rather  an  active 
type  of  symptoms.     It  seems  best  to  take  up  the  latter  separately. 


Fig.  422. — Mrs.  K.  Author's  case  at  Manhattan  State  Hospital,  Wards  Island. 
Gall-stones  at  +  +  •  Hyperchlorhydria;  trace  of  bile  in  urine.  Radiography  by  D.  J. 
Kelliher.  No  jaundice  at  time  of  radiograph;  conjunctivae  clear.  Patient  has  had  attacks 
of  jaundice.  Gall-bladder  tender.  Chronic  appendicitis.  Stool  shows  a  large  number 
of  fatty  acid  crystals  and  incomplete  absorption  of  products  of  fat  digestion.  Early 
stage  of  chronic  pancreatitis.  To  be  operated  immediately.  Bile  passes  into  intestines 
at  present  time  in  most  part,  though  slight  absorption  of  same. 

The  onset  of  the  symptoms  may  be  apparently  sudden,  due  to  an 
exacerbation,  or  they  may  be  gradual. 

Pain. — Pain  is  usually  present  during  an  exacerbation,  varying  from 
a  dull  ache  or  discomfort  to  that  of  a  lancinating  or  colicky  type.  In 
the  latter  instance,  calculi  are  probably  responsible  in  most  cases.  In 
many,  the  pain  is  in  the  epigastric  region,  though  it  may  radiate  to  the  back 
in  the  midscapular  region.  Occasionally  it  radiates  to  the  right,  and  it 
may  start  beneath  the  right  or  left  costal  margin.  There  appears  to  be 
no  definite  relation  of  the  time  of  eating  or  the  character  of  the  food  to 
the  commencement  of  the  pain,  and  this  may  be  sometimes  of  service 
in  differentiating  pancreatic  pain  from  that  of  gastric  or  duodenal  ulcer. 

Nausea  and  Vomiting. — Nausea  or  vomiting,  or  both  conditions  in 
association,  occur  quite  frequently  in  attacks.     With  nausea  there  may 


I024  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

be  anorexia,  offensive  eructations,  heart-burn,  flatulency,  and  distaste  for 
fats  or  meat.  Carbohydrates  seem  to  cause  in  some  the  most  disturbance. 
Sailer  states  that  the  administration  of  a  large  amount  of  glucose  is 
particularly  distressing  to  these  patients. 

Opie  has  called  attention  to  persistent  vomiting^  in  some  cases  of 
chronic  interlobular  pancreatitis.  It  seemed  to  indicate  a  relationship 
between  gastro-intestinal  disturbance  and  a  chronic  pancreatitis. 

Gastritis,  or  gastroduodenitis  may  be  associated  with  chronic  pan- 
creatitis, and  in  some  cases  these  factors  may  be  the  cause  of  the  vomiting. 

Vomiting  also  occurs  with  biliary  catarrh. 

The  vomiting  of  chronic  pancreatitis  is  not  characteristic,  though 
it  may  contain  mucus  and  bile,  and  eructations  of  distressing  character 
may  be  present. 

Jaundice. — Jaundice  is  another  important  symptom.  In  Deaver's- 
cases  it  was  present  in  24  patients  at  the  time  of  operation  and  absent 
in  14.  In  about  two-thirds  of  all  cases  the  common  bile-duct  passes 
through  the  head  of  the  pancreas,  so  that  an  inflammation  of  this  part  of 
the  organ  will  interfere  with  the  free  exit  of  bile.  Undoubtedly,  many 
cases  of  so-called  catarrhal  jaundice  can  be  so  explained.  On  the  other 
hand,  a  great  degree  of  inflammation  of  the  pancreas  may  be  present, 
with  no  jaundice,  when  the  duct  does  not  pass  through  the  head  of  the 
gland.  A  certain  percentage  of  jaundice  cases  may  be  due  to  obstruction 
from  a  calculus,  or  to  extension  from  a  catarrhal  duodenitis.  In  some 
cases  the  jaundice  may  come  on  without  pain,  and  it  may  be  continuous. 

In  others,  rapid  wasting  and  loss  of  strength  are  associated  with  the 
jaundice,  so  that  malignant  disease  of  the  pancreas  may  he  simulated. 
On  operation  the  head  of  the  pancreas  may  be  so  hard  and  nodular  as 
to  resemble  carcinoma  on  palpation.  Occasionally  the  neighboring  glands 
may  also  be  enlarged,  so  that  the  simulation  is  complete. 

More  frequently,  jaundice  is  preceded  by  pain,  sometimes  like  that  of 
gall-stone  colic  when  such  is  present,  or  at  other  times  the  pain  may  be 
less  severe  and  not  colicky. 

Pain,  intermittent  jaundice,  and  attacks  of  fever  (Charcot's  hepatic 
intermittent  fever)  may  occur,  and  yet  no  stone  be  found  at  operation. 
Possibly  it  has  escaped  from  the  duct,  though  this  simulation  of  gall-stone 
attack  may  occur  with  chronic  pancreatitis. 

The  jaundice  may  vary  from  a  slight  tinge  to  black  jaundice. 

Opie  holds  the  view  that  in  most  cases  jaundice  is  due  to  cholelithiasis 
or  some  other  hepatic  disease,  preceding  or  accompanying  the  chronic 
pancreatitis. 

Digestive  Symptoms. — With  serious  disturbance  of  the  pancreatic  func- 
tions there  are  loss  of  weight  and  impairment  of  appetite.  The  appetite 
may  persist  in  some  cases.  In  some  there  is  no  disgust  for  meat.  The  loss 
of  weight  and  strength,  especially  in  the  cases  with  jaundice,  may  be  so  rapid 
as  to  simulate  cancer.     In  ordinary  cases  marked  wasting  does  not  occur. 

Temperature. — The  temperature  is  usually  normal  in  prolonged  cases, 
but  fever  may  be  present  during  an  exacerbation  of  the  disease.     In  the 

^  Vomiting  of  blood,  with  hemorrhage  from  the  intestines  and  other  mucus  mem- 
branes is  of  bad  prognosis. 

-Jour.  Amer.  Med.  Assoc,  April  15,  1911. 


ACUTE    PANCREATITIS CHRONIC    PANCREATITIS  IO25 

cases  coming  to  the  surgeon  to  secure  relief,  fever  has  been  usually  present, 
sometimes  varying  from  99°  to  io3°F.  With  an  associated  cholangitis, 
fever,  chills,  and  sweating  occur. 

Bowels. — The  bowels  are,  as  a  rule,  constipated  and  flatulence  is 
present.  In  a  few  cases  there  is  diarrhea.  Only  with  advanced  pancreatitis 
do  we  have  the  frequent  pale,  offensive,  greasy,  and  btdky  movements 
(steatorrhea). 

Physical  Examination. — Physical  examination  may  afford  no  positive 
information,  but  may  aid  in  excluding  other  abdominal  conditions.  Epi- 
gastric tenderness  and  muscular  rigidity  of  the  recti  in  this  region  may  be 
present  during  an  exacerbation  of  the  disease.  When  present,  it  is 
impossible  to  detect  a  mass  except  possibly  under  anesthesia.  At  other 
times,  in  patients  with  thin  abdominal  walls,  or  when  ptosis  of  the  colon  or 
stomach  are  present,  it  may  be  possible  to  palpate  the  enlarged  head  of 
the  pancreas;  but  in  the  majority  of  cases  it  cannot  he  done.  When  a  mass 
can  be  palpated,  its  relation  to  the  stomach  and  colon  can  be  determined 
by  inflating  the  stomach  with  air  or  with  carbonic  acid  gas.  Resonance 
on  percussion  from  the  overlying  stomach,  slight  movement  on  deep 
inspiration,  and  communicated  non-expansile  pulsation  are  character- 
istic of  the  mass  (enlarged  pancreas).  The  relation  of  the  tumor  to  the 
transverse  colon  can  be  determined  by  inflating  the  colon  with  air  or 
carbonic  acid  gas. 

Tenderness. — Tenderness  in  the  epigastrium  is  sometimes  present, 
though  in  some  cases  it  may  not  be  marked.  It  may  be  absent.  Tender- 
ness may  be  over  Mayo  Robson's  point  (above  and  a  little  to  the  right 
of  the  umbilicus)  or  in  the  midepigastrium.  In  a  number  of  cases  it  has 
been  found  beneath  the  right  costal  margin,  but  associated  disease  of  the 
gall-bladder  probaby  accounted  for  this.  Occasionally  tenderness  is 
found  beneath  the  left  costal  margin,  and  rarely  it  may  be  general.  If 
found  over  the  head  of  the  pancreas  it  is  of  value. 

Musctdar  Rigidity. — This  occurs  in  the  epigastrium,  though  in  some 
cases  it  may  be  found  in  the  right  hypochondrium,  over  the  gall-bladder. 
It  may  be  absent. 

Gall-bladder. — In  the  chronic  cases  of  long  duration  a  distended  gall- 
bladder may  be  found,  such  as  occurs  with  carcinoma  of  the  head  of  the 
pancreas.  With  jaundice  diie  to  stone  in  the  common  duct  the  gall-bladder 
is  nearly  always  contracted.  > 

Liver. — The  liver  is  found  enlarged  in  some  patients.  The  association 
of  hypertrophic  cirrhosis  of  the  liver  with  interlobular  pancreatitis  has 
already  been  noted. 

TJte  Blood. — The  blood  quite  frequently  shows  a  secondary  anemia 
which  is  seldom  grave,  the  hemoglobin  also  being  moderately  reduced. 
Leukocytosis  is  usually  absent  except  during  the  acute  exacerbation,  when 
it  is  moderate  and  there  is  increase  in  the  polynuclears.  The  coagulation 
period  should  be  tested,  as  it  is  frequently  delayed. 

When  atrophic  cirrhosis  of  the  liver  and  arteriosclerosis  accompany 

diabetes  mellitus,  the  latter  condition  is  due  to  the  interacinar  form  of 

chronic  pancreatitis.     Diabetes  with  hemachromatosis  results  from  chronic 

interacinar  pancreatitis.     One  may  say  that  glycosuria  and  other  symp- 

6s 


I026  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

toms  of  diabetes  mellitus  are  distinctive  of  chronic  interacinar  pancreatitis. 
Temporary  glycosuria  may  occur  during  an  exacerbation  of  pancreatitis. 

Gastric  Analysis.^ — Deaver  reports  in  his  cases  that  there  is  usually 
subacidity  and  no  further  abnormality.  The  writer  found  mild  hyper- 
chlorhydria  in  an  incipient  case. 

Stools. — Examination  of  the  stools  may  give  important  information. 
In  some  instances  they  are  clay  colored.  One  must  determine  to  what 
extent  absence  of  bile  influences  this  condition,  and  the  test  for  stercobilin 
must  be  carried  out.     Generally  the  color  is  due  to  excess  of  fat. 

In  cases  of  chronic  pancreatic  disease  the  total  amount  of  unabsorbed 
fat  may  reach  50  to  60  per  cent.,  and  up  to  90  per  cent,  with  malignant 
disease  of  the  gland.  Miiller  finds  that,  though  the  total  per  cent,  of 
fecal  fat  may  not  be  above  normal,  yet  the  proportion  of  split  fat  is  always 
decreased,  averaging  about  40  per  cent,  of  the  total  fat.  Katz  holds  that 
a  diminution  of  the  split  fat  below  70  per  cent,  of  the  total  fecal  fat  signifies 
disease  of  the  pancreas,  except  in  nursing  infants  and  in  patients  with  severe 
diarrhea.  Steatorrhea  is  present  only  in  the  most  advanced  cases.  Excess 
of  muscle-fibers  in  the  stools  is  very  rare.  In  the  early  case  noted  above, 
there  were  incomplete  absorption  of  the  products  of  fat  digestion  and  a 
large  number  of  fatty  acid  crystals. 

Cammidge  Reaction. — The  Cammidge  reaction  in  the  urine,  in  5  5  cases 
of  chronic  pancreatitis  confirmed  by  Deaver^  at  operation,  was  present 
in  18  cases  (32  per  cent.).  In  other  series  the  ratio  was  not  as  good — 
one-fifth  of  the  cases  positive  in  pancreatitis  as  compared  with  one-sixth 
positive  when  no  pancreatitis  was  present;  and  in  summing  up  all  cases  in 
which  the  condition  of  the  pancreas  was  determined  at  operation,  Deaver 
found  the  pancreatic  reaction  was  obtained  about  two  and  a  half  times  as 
frequently  when  the  pancreas  was  diseased  as  when  it  was  not.  This 
does  not  correspond  to  the  reports  of  Robson  and  Cammidge.  According 
to  Deaver,  in  a  recent  series,^  he  found  it  present  in  25  per  cent.  Later 
reports  by  Deaver^  with  an  experience  of  over  500  cases  state  that  he  has 
been  unable  to  derive  any  assistance  from  this  reaction.  The  writer  is 
very  dubious  of  the  value  of  the  Cammidge  reaction.  Only  recently,  in 
an  undoubted  case  of  advanced  pancreatitis  with  steatorrhea,  repeated 
tests  were  negative.  The  urine  should  be  tested  for  bile  and  sugar.  Sugar 
may  appear  during  an  exacerbation  of  an  attack  and  clear  up  later.  Per- 
sistent glycosuria  suggests  diabetes.  Under  Testing  the  Pancreatic  Func- 
tions the  most  desirable  methods  are  described,  and  those  the  author  pre- 
fers are  referred  to  at  the  end  of  that  chapter,  notably  the  general  method 
of  Testing  the  Intestinal  Functions.  A  marked  hemorrhagic  tendency  is 
of  serious  import  and  may  show  the  approach  of  a  fatal  termination. 

Differential  Diagnosis. — With  cancer  of  the  head  of  the  pancreas  the 
onset  is  generally  gradual  and  painless,  and  the  age  of  the  patient  is 
usually  over  forty  years.     Jaundice"  appears,   which  is  absolute.     The 

^  Hypoacidity  and  achylia  occur  in  advanced  cases. 
-Jour.  Amer.  Med.  Assoc,  April  15,  1911. 
^  Ibid.,  July  I,  1911. 
*  N.  Y.  Med.  Jour.,  Mar.  23,  191 2. 

^  The  writer  reports  carcinoma  of  the  tail  of  the  pancreas,  with  no  jaundice  and 
pressure  stenosis  of  the  colon  with  cachexia. 


ACUTE    PANCREATITIS — CHRONIC  PANCREATITIS  IO27 

gall-bladder  is  generally  distended,  but  is  not  tender.  The  liver  enlarges 
from  bile  stasis,  but  there  are  no  nodules.  Occasionally  there  is  a  meta- 
static tumor  of  the  inner  side  of  the  gall-bladder.  The  loss  of  weight  and 
strength  is  rapid  and  anemia  increases.  Fever  is  generally  absent  and 
the  pulse  is  slow  and  feeble.  Ascites  with  edema  of  the  lower  limbs  may 
occur  late  in  the  disease.  Carcinoma  is  sometimes  difficult  to  differentiate 
from  severe  chronic  pancreatitis  with  jaundice.  The  course  of  carcinoma 
is  more  rapid  and  the  history  short.  Cammidge  holds  that  the  pancreatic 
reaction  in  the  urine  occurs  in  about  25  per  cent,  of  cases  of  cancer; 
undigested  fat  is  present  in  the  feces  in  some  cases,  of  which  only  a  small 
proportion  consists  of  fatty  acids. 

When  the  carcinomatous  growth  lies  in  the  common  bile-duct  above 
the  opening  of  the  pancreatic  duct,  the  loss  of  flesh  and  strength  are  not 
as  apt  to  be  as  rapid. 

Syphilis. — This  should  be  excluded  by  testing  for  the  Wassermann  or 
Noguchi  reaction. 

Cancer  of  the  Liver. — With  this  condition  there  is  an  irregular  enlarge- 
ment of  the  organ,  and  it  is  nodular  to  the  feel.  There  are  a  rapid  loss  of 
weight  and  strength,  the  jaundice  is  less  intense,  and  there  are  no  fever 
or  paroxysmal  pains. 

Gall-stones. — With  gall-stones  there  is  a  long  history  of  spasmodic 
pains  without  jaundice,  the  pain  commencing  in  the  right  hypochondrium 
and  radiating  to  the  right  shoulder-blade,  as  a  rule.  Later,  attacks  of 
pain  occur,  followed  by  jaundice,  and  often  recurrent  pains,  with  increased 
jaundice  and  with  chills  and  intermittent  fever.  Head's  zone  for  the  gall- 
bladder is  present.  In  the  active  stage  there  is  leukocytosis  with  increase 
in  the  polynuclears. 

The  tenderness  with  gall-stones  is  over  the  gall-bladder,  and  fre- 
quently lower  down  in  the  case  of  pancreatitis  and  nearer  the  middle  line. 
Robson  holds  that  the  Cammidge  reaction  and  examination  of  the  stools 
are  of  service  to  exclude  pancreatitis.  Frequently  the  two  conditions — • 
gall-stones  and  chronic  pancreatitis — are  associated,  and  operation  alone 
will  determine  the  presence  of  the  latter.  The  writer  has  already  referred 
to  the  fact  that  in  some  cases,  chronic  pancreatitis  presents  symptoms  of 
gall-stones  alone.  Removal  of  an  impacted  stone  and  drainage  of  the 
gall-bladder  will  at  times  cure  the  chronic  pancreatitis.  The  :»;-rays  will 
usually  determine  the  presence  of  gall-stones  either  by  the  direct  method 
or  by  the  presence  of  deformity  of  the  duodenum.  In  Fig.  422  gall-stones 
are  demonstrated  to  be  the  cause  of  the  incipient  pancreatitis. 

With  catarrh  of  the  bile-ducts  there  is  at  times  a  history  of  chronic 
gastroduodenitis,  though  it  may  be  of  pancreatic  origin. 

The  jaundice  and  loss  of  flesh  come  on  without  pain.  With  chronic 
appendicitis,  the  determination  of  the  sensitive  appendix  at  McBurney's 
point  or  Morris'  point  and  of  the  appendix  Head  zone  are  of  value. 

Prognosis. — If  the  diagnosis  be  made  sufficiently  early,  free  drainage 
of  the  biliary  tract,  and  hence  of  the  pancreas,  may  result  in  cure. 

The  disease  may  progress  for  months  or  even  for  years,  and  the  well- 
marked  cases  may  eventually  die  from  asthenia,  diabetes,  or  the  hemor- 
rhagic diathesis.     A  hemorrhagic  tendency  is  of  bad   prognostic  import. 


I028  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Commencing  glycosuria,  intermitting  but  increasing  in  frequency,  is 
suggestive  of  commencing  interacinar  involvement;  and  persistent 
glycosuria,  of  diabetes. 

Treatment. — Medicinal. — If  gastro-intestinal  catarrh  is  present,  proper 
dietetic  measures  should  be  undertaken  and  the  usual  treatment  accorded 
to  these  conditions. 

For  attacks  of  gall-stones,  olive  oil,  the  salicylates,  probilin  pills,  etc.. 
may  be  administered.  Duodenal  or  gastric  ulcer,  alcoholism,  syphilis, 
or  arteriosclerosis  should  receive  appropriate  treatment  if  they  are  be- 
lieved to  be  factors.  Wet  packs,  rest  in  bed,  the  sparing  use  of  carbo- 
hydrates, and  the  administration  of  the  pancreatic  extracts,  as  holadin 
gr.  V  t.i.d.  and  secretin^  gr.  i  t.i.d.,  to  stimulate  pancreatic  secretion 
should  he  tried.  Mild  mercurial  purges  may  be  indicated.  In  all  cases, 
whether  or  not  hemorrhage  has  occurred  for  several  days  before  any 
operation,  chlorid,  or  preferably,  lactate  of  calcium,  60  grains  (4.0)  a  day 
in  divided  doses,  should  be  given.  It  should  be  continued  a  week  after 
operation  or  until  normal  blood  clotting  time  is  present  and  may  be 
given  by  rectum  by  enema  or  proctoclysis  if  indicated. 

Human  serum  may  be  injected  hypodermically  if  hemorrhage  occur. 

Surgery. — For  ulcer  of  the  stomach  or  duodenum — if  these  are  factors 
— gastro-enterostomy  may  be  required.  Free  drainage  of  the  biliary  tract 
and,  through  this,  drainage  of  the  pancreatic  ducts  will  in  many  cases 
enable  the  pancreas  to  cast  off  the  infection  and  resume  its  normal  func- 
tions. Gall-stones  should  be  removed  from  the  gall-bladder  and  the 
common  bile-duct  as  well,  and  the  head  of  the  pancreas  should  be  thor- 
oughly explored,  and  any  calculus  lying  therein  or  in  the  pancreatic  duct 
should  be  removed. 

Cholecystotomy  or,  in  some  cases,  cholecystenterostomy  (establishing  an 
artificial  opening  between  the  gall-bladder  and  duodenum)  afford  the  best 
method  of  drainage.  Junction  of  the  gall-bladder  with  the  colon,  the 
writer  believes,  increases  the  liability  of  infection. 

The  writer's  case,  with  colon  b.  bacilluria,  received  hexamethlyenamin 
and  sodium  benzoate  60  grs.  each  daily  and  the  usual  treatment  of  colon 
bacillus  infection  as  described  in  that  section. 

Diet. — If  temporary  glycosuria  or  diabetes  mellitus  be  present,  appro- 
priate diet  should  be  instituted.  With  the  interlobular  type  of  pancreatitis 
fats  should  be  given  in  the  form  of  emulsions  and  milk  is  of  great  value. 
Feeding  should  be  forced  by  repeated  small  meals  and  general  nutrition 
should  be  improved.  The  bowels  should  be  regulated  to  one  movement 
daily  and  diarrhea  checked. 

*  Prosecretin,  grs.  3  t.i.d.  may  be  substituted. 


CHAPTER  XLIV 

FAT   NECROSIS— TUBERCULOSIS— SYPHILIS— PANCREATIC 

CALCULI 

FAT  NECROSIS 

Balser^  first  directed  attention  to  this  condition.  In  several  autopsies 
he  observed  in  the  fat  about  the  pancreas,  small  white  opaque  areas, 
which  subsequently  were  demonstrated  to  be  composed  of  necrotic  fat 
cells.  One  occasionally  finds  these  minute  foci  limited  to  fat  within  or 
upon  the  pancreas,  but  usually  the  process  is  disseminated. 

Location  and  Appearance  of  Fat  Necrosis. — Fat  necrosis  is  of  impor- 
tance to  the  surgeon,  as  it  indicates  disease  of  the  pancreas.  When  the 
abdomen  is  opened,  the  omentum,  and  at  times  other  fat,  is  found  to  be 
studded  with  small  round  oval  areas,  opaque,  white  or  yellow  in  color, 
in  contrast  to  the  translucent  golden  yellow  color  of  normal  fat. 

Occasionally  each  area  of  necrotic  fat  is  surrounded  by  a  narrow 
hemorrhagic  zone. 

The  lesions  are  usually  most  marked  near  the  pancreas,  and  are  generally 
limited  to  the  fat  of  the  abdominal  cavity.  Two  cases  of  fat  necrosis  in 
the  subcutaneous  tissue  of  the  abdomen  have  been  reported  by  Hause- 
mann.2  Areas  of  fat  necrosis  have  been  found  in  the  mesentery,  in  the 
subperitoneal  fat  of  the  abdominal  wall,  in  the  subpericardial  and 
subpleural  fat,  and  in  the  pericardial  fat. 

Occurrence.— Fat  necrosis  associated  with  pancreatic  disease  has  been 
frequently  noted  in  stout  patients,  in  fact  in  about  50  per  cent,  of  cases. 
In  the  majority  it  is  found  with  hemorrhagic  necrosis  or  gangrene  of  the 
pancreas,  is  rare  with  suppurative  pancreatitis,  and  occasionally  occurs 
with  chronic  pancreatitis.  It  may  be  present  with  pancreatic  calculi, 
cyst  of  the  pancreas,  and  with  gall-stones  or  carcinoma  which  close  the 
pancreatic  duct.  Fat  necrosis  with  acute  hemorrhagic  pancreatitis  is 
depicted  under  that  subject. 

Pathology. — The  changes  in  the  fat  cells  are  due  to  splitting  of  the 
neutral  fat  into  fatty  acid  and  glycerin.  The  fatty  acids  are  deposited 
in  needle-like  crystals  in  the  cells.  The  latter  lose  their  nuclei  and  are 
necrotic.  The  soluble  glycerin  is  absorbed.  The  fatty  acids  subsequently 
unite  with  calcium  and  form  irregular  or  globular  masses  of  lime  salts. 
The  outline  of  the  cells  is  more  or  less  preserved. 

It  has  been  demonstrated  by  Benda^  that  acetate  of  copper  will  com- 
bine with  the  fatty  acid  in  the  necrotic  fat,  and  will  produce  a  greenish- 
blue  compound,  and  that  calcium  salts,  are  less  markedly  stained,  while 

^  Ueber  Fettnekrose,  Virchow's  Archiv,  1882,  xc,  520. 

2  Berliner  Med.  Gesellsch.  Sitzung  vom  4  Dec,  1889;  Berliner  Klin.  Woch.,  1889, 
XXV,  1 1 15. 

^  Virchow's  Archiv,  1900,  clxi,  194. 

1029 


1030  DISEASES    OF   THE    STOMACH   AND   INTESTINES 

neutral  fats  are  unchanged.  It  is  thus  possible  to  demonstrate  areas  of 
necrosis  which  are  not  visible  to  the  eye.  A  half-saturated  solution  of 
acetate  of  copper  is  employed  for  this  test. 

The  foci  of  fat  necrosis  may  disappear  entirely.  This  has  been 
demonstrated  by  subsequent  operation  on  patients  in  whom  they  were 
formerly  observed. 

Etiology  of  Fat  Necrosis. — Some  have  attempted  to  impute  the 
occurrence  of  fat  necrosis  to  the  action  of  microorganisms,  since  the 
colon  bacillus  and  various  micrococci  have  been  found.  The  invasion 
of  the  fat  by  these  bacteria  is  believed  to  be  secondary. 

The  products  of  the  pancreas  are  the  active  cause  of  fat  necrosis. 

Flexner,^  Opie,^  and  others  have  demonstrated  on  animals  that 
when  conditions  were  produced  which  a£Forded  opportunity  for  the  escape 
of  pancreatic  secretion  into  the  tissues  surrounding  the  gland,  fat  necrosis 
resulted. 

It  has  been  concluded  that  fat  necrosis  is  produced  by  the  fat-splitting 
ferment  of  the  pancreatic  juice. 

Flexner^  has  demonstrated  that  necrotic  fat  tissue  in  the  human 
being  contains  an  enzyme  which  can  split  up  neutral  butter  fat  and  set 
free  fatty  acids. 

Some  have  claimed  that  fat  necrosis  may  occur  without  lesion  of 
the  pancreas.  A  case  associated  with  duodenal  ulcer  is  reported  in 
this  volume.  The  presence  of  an  aberrant  pancreas  may  explain  some 
cases.  Fat  necrosis  without  the  association  of  pancreatic  disease  is  a 
rare  occurrence. 

Occasionally  (postmortem)  minute  foci  of  fat  necrosis  are  found  in 
and  upon  the  pancreas. 

The  treatment  of  fat  necrosis  when  determined  at  operation  is  that  of 
the  pancreatic  disease  upon  which  it  depends. 

TUBERCULOSIS  OF  THE  PANCREAS 

Tuberculosis  of  the  pancreas  occurs,  as  a  rule,  in  connection  with 
tuberculosis  of  other  organs,  and  the  blood-vessels  usually  furnish  the 
channel  by  which  the  bacilli  are  distributed  to  the  gland.  In  12  out  of 
1 28  autopsies  with  tuberculosis  in  other  regions,  Krudewetzky*  found 
miliary  tubercles  of  the  pancreas,  of  which  six  were  in  children  in  18  cases 
of  acute  miliary  tuberculosis.  The  tubercles  usually  lie  within  the 
lobules,  and  less  frequently  in  the  interlobular  tissue.  They  rapidly 
undergo  caseation.  In  cases  of  chronic  tuberculosis  large  tubercles 
occasionally  occur. 

Multiple  small  tuberculous  deposits  are  found  irregularly  scattered 
through  the  pancreas,  or  several  large  masses,  which  may  caseate  and 
form  cavities  that  open  into  the  stomach,  or  some  adjacent  organ.  A 
small  tuberculous  lymphatic  gland  has  been  removed  from  the  head  of 

1  Contributions  to  the  Science  of  Medicine,  Johns  Hopkins  Hosp.  Reports,  1900, 
ix,  850. 

"^  The  Pancreas. 

'  Jour,  of  Exper.  Med.,  1897,  ii,  413. 

*  Zeit.  f.  Heilk.,  1892,  xiii,  loi. 


PANCREATIC    CALCULI  IO3I 

the  pancreas.  Tuberculosis  of  the  pancreas  may  occur  by  extension  from 
neighboring  organs. 

Primary  tuberculosis  of  the  pancreas,  though  rare,  has  been  reported 
by  Mayo,^  Aran,^  and  Chvostek.' 

Symptoms. — Pain  in  the  epigastrium,  vomiting,  local  tenderness, 
and,  at  times,  jaundice  may  be  present.  A  palpable  tumor  just  above 
the  umbilicus  was  found  by  Mayo  in  one  case.  Functional  disturbances 
of  the  organ  may  also  occur.  The  diagnosis  is  probable  from  the  usual 
association  of  the  process  elsewhere. 

SYPHILIS 

Congenital  Syphilitic  Pancreatitis. — Attention  was  first  called  to 
the  frequency  of  congenital  syphilis  of  the  pancreas  by  the  investigations 
of  Birch-Hirschfeld,*  who  found  it  in  that  organ  in  13  out  of  23  children, 
and  in  another  series  in  29  out  of  124  syphilitics.  The  pancreas  would 
seem  to  be  affected  in  about  22  to  23  per  cent,  of  all  cases  of  syphilis  of  the 
newborn. 

Pathology. — The  pancreas  is  enlarged  and  firm,  and  there  is  a  diffuse 
interstitial  pancreatitis  with  proliferation  of  interlobular  and  interacinar 
tissue  which  penetrates  between  the  cells  of  the  acini.  This  is  followed  by 
destruction  of  the  parenchyma,  which  last  probably  atrophies.  There  is 
a  syphilitic  peri-arteritis.  The  islands  of  Langerhans  are  not  invaded 
by  the  new  growth  of  interstitial  tissue.  Small  gummata  (syphilitic 
necrosis)  are  occasionally  found  in  the  newly  formed  stroma. 

Acquired  Syphilis. — Gummata  and  syphilitic  induration,  resembling 
syphilitic  cirrhosis  of  the  liver,  may  occur.  The  bands  of  tissue  are 
irregular,  scar-like,  and  differ  from  the  diffuse  increase  of  tissue,  such  as 
occurs  with  the  interlobular  or  interacinar  types  of  chronic  pancreatitis. 

Symptoms. — Usually  one  finds  associated  symptoms  of  the  tertiary 
stage  in  these  acquired  cases.  These  may  be  disturbances  of  the  pan- 
creatic functions,  evidences  of  chronic  pancreatitis,  and,  at  times,  diabetes. 

Diagnosis. — The  Wassermann  or  Noguchi  reactions  should  be  tested 
for  in  addition  to  a  careful  anamnesis  and  examination. 

Treatment. — This  should  be  as  of  syphilis — mercury  and  iodids — or, 
preferably,  "606"  or  neosalvarsan  should  be  injected,  followed  by  mer- 
cury and  the  iodides. 

PANCREATIC  CALCULI 

Pancreatic  calculi  are  rare,  and  among  1500  autopsies  at  the  Johns 
Hopkins  Hospital  only  two  cases  were  discovered.  The  earliest  report  of 
this  condition  is  by  Panarol  and  Galea  in  the  year  1667. 

Guidiceandra,  in  1896,  records  48  cases;  and  in  1903  Oser  states  that 
there  were  only  70  cases  reported.  Lazarus  has  since  collected  80  cases. 
Mayo  and  Robson  have  reported  others  since  that  date. 

*  Cited  by  Senn,  Outlines  of  Human  Pathology. 
2  Ibid. 

'  Wiener  med.  Blatter,  1879,  ii,  791. 

*  Gerhardt's  Handbuch  d.  KindQtkrankheiten,  iv.,  Abt.,  753,  Tubingen,  j88o. 


1032  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

Occurrence. — Pancreatic  calculi  are  more  common  in  men  than 
in  women.  Lazarus^  collected  57  cases,  of  which  47  occurred  in  men 
and  10  in  women. 

Age. — Thirty-seven  of  these  cases  were  in  patients  between  thirty 
and  forty  years  of  age. 

Pathology. — Calculi  are  not  found  in  the  healthy  pancreas,  and  prob- 
ably these  pancreatic  concretions  are  a  result  of  catarrh  of  the  ducts, 
with  stagnation  of  secretion,  with  which  bacterial  infection  is  associated. 

The  concretions  in  the  ducts  may  be  like  sand,  but  generally  there 
are  one  or  more  small  stones.  As  many  as  one  hundred  have  been  re- 
ported. The  ducts  may  be  lined  with  calcareous  material,  so  as  to  com- 
pletely or  nearly  close  their  lumen. 

Usually  the  calculi  consist  of  calcium  carbonate  or  calcium  phos- 
phate, though  a  case  has  been  reported  which  contained  cholesterin  in 
considerable  amount,  and  another  which  consisted  chiefly  of  calcium 
oxalate. 

Biliary  calculi  at  times  make  their  way  into  the  pancreatic  duct, 
and  this  has  resulted  in  suppuration.  A  pancreatic  calculus  which  lodges 
at  the  duodenal  end  of  the  pancreatic  duct  may  be  stained  with  bile- 
pigments  and  be  covered  with  a  layer  of  cholesterin.  The  duct  of  Wir- 
sung  is  narrowest  where  it  passes  through  the  wall  of  the  duodenum, 
and  calculi  have  a  tendency  to  lodge  above  this  point. 

The  outflow  of  the  pancreatic  secretion  may  be  entirely  obstructed, 
and  the  duct  may  become  dilated  above  the  point  of  obstruction.  True 
cysts  rarely  result,  but  they  have  been  reported.  Obstruction  of  the  duct 
by  calculi  is  usually  associated  with  bacterial  infection,  and  produces 
the  most  advanced  type  of  sclerosis.  The  Bacillus  coli  has  been  found 
in  two  calculi.  The  chronic  inflammation  is  of  the  interlobular  type,  and 
the  islands  of  Langerhans  are  usually  not  affected.  They  may  finally 
become  involved  in  the  advanced  sclerosis. 

Pancreatic  calculi  are  opaque  to  the  ic-rays,  and  we  thus  have  a  means 
of  diagnosing  their  presence  and  of  differentiating  them  from  biliary  calculi, 
which  are  not  readily  seen  and  may  not  even  be  visible  in  a  rontgenograph. 
The  presence  of  the  Cammidge  reaction,  when  such  is  present,  Robson 
believes,  will  confirm  the  diagnosis  by  demonstrating  the  associated 
chronic  pancreatitis. 

The  stones  are  round,  oval  or  elongated,  and  usually  smooth.  They 
may  occur  in  all  parts  of  the  ducts,  though  they  are  found  most  frequently 
in  the  head  of  the  pancreas.     They  may  also  be  branched. 

One  stone  has  been  recorded  measuring  2>^  by  >^  inch,  weighing  200 
grains,  and  a  second  one  weighing  20  ounces.  They  are  pale  in  color, 
but  may  be  white,  or  when  near  the  common  duct  may  be  covered  with 
cholesterin  and  stained  with  bile. 

Obstruction  to  the  flow  of  the  pancreatic  juice  from  an  impacted 
calculus  may  cause  escape  of  the  secretion  into  the  tissues,  so  that  fat 
necrosis  results.  A  pancreatic  calculus  in  the  diverticulum  of  Vater  may 
occlude  the  common  bile-duct  and  cause  jaundice.     Ulceration  of  the 

*  Beitrag  zur  Pathologic  und  Therapie  der  Pankreaserkrankungen  mit  bensonderer 
Berucksichtigung  der  Cysten  und  Steine,  Berlin,  1904. 


PANCREATIC    CALCULI  IO33 

mucosa  of  the  duct  may  be  caused  by  an  impacted  calculus,  and  pancreatic 
abscess  result. 

Etiology. — The  writer  has  already  referred  to  the  fact  that  obstruction 
to  the  outflow  of  the  pancreatic  juice  with  associated  bacterial  infection 
are  probably  factors.  Various  forms  of  bacteria  have  been  found  within 
the  calculi.  Cholelithiasis  may  occur  in  association  with  pancreatic 
lithiasis,  and  the  former  may  produce  obstruction  of  the  pancreatic  duct 
and  favor  stasis.  Pancreatic  calculi  are  sometimes  found  in  pancreatic 
cysts,  possibly  resulting  from  the  retained  secretion. 

Symptoms. — Pancreatic  calculi  have  been  found  on  autopsy  in  persons 
who  have  never  suffered  with  symptoms  that  could  be  referred  to  the 
pancreas.  In  some  the  symptoms  may  be  vague.  The  presence  of  a 
cyst,  a  secondary  abscess,  and  the  degree  of  advancement  of  the  chronic 
pancreatitis  modify  the  symptoms. 

There  is  often  pain  in  the  epigastrium,  which  may  be  slight  but 
continuous,  or  it  may  be  paroxysmal,  resembling  biliary  colic;  sometimes 
it  is  agonizing  in  character,  and  may  be  associated  with  vomiting,  hiccup, 
cold  sweats,  and  collapse;  chills  and  fever  may  at  times  occur.  The 
attacks  may  be  brought  on  by  exertion,  or  they  may  be  irregular,  occurring 
at  any  time,  day  or  night.  The  pain  frequently  comes  on  in  sharp,  colicky 
attacks,  less  severe  than  gall-stones,  and  may  radiate  toward  the  inferior 
angle  of  the  left  scapula.  A  sensation  of  soreness  or  stiffness  is  sometimes 
noticed  for  several  days  after  an  attack.  Fragments  of  stone  may 
subsequently  be  found  in  the  stool,  which,  when  analyzed,  consist  chiefly 
of  carbonate  or  phosphate  of  calcium.  In  one  case  of  Kinnicutt's^  the  pain 
began  in  the  back  and  then  ran  around  the  right  side  along  the  lower 
intercostal  spaces,  while  in  another  case  the  pain  began  between  the 
scapulae  and  ran  through — not  around — the  body  into  the  epigastrium, 
where  it  became  localized  to  the  right  of  the  middle  line.  The 
localization  of  the  pain,  though  more  frequently  to  the  left,  is  not  always 
characteristic. 

Jaundice,  which  occurs  with  pancreatic  calculi,  may  be  due  to  as- 
sociated gall-stones,  but  a  pancreatic  calculus  may  occlude  the  common 
bile-duct  and  thus  produce  it.  Lancereaux  records  glycosuria  in  12  out 
of  40  cases  of  pancreatic  calculi.  Sugar  may  be  observed  at  intervals. 
Diabetes  mellitus  or  glycosuria  accompany  pancreatic  lithiasis  with  a 
fair  degree  of  frequency,  and  Lazarus  has  found  one  of  these  conditions 
present  in  36  out  of  80  cases. 

The  disturbance  of  carbohydrate  metabolism  is  not  produced  by 
the  occlusion  of  the  ducts,  but  by  the  chronic  interlobular  pancreatitis, 
and  it  occurs  only  when  this  condition  is  so  far  advanced  that  the  islands 
of  Langerhans  are  involved. 

Alimentary  glycosuria  indicates  a  less  advanced  stage  of  the  pan- 
creatitis. 

Steatorrhea,  when  it  is  present,  is  an  aid  to  diagnosis.  It  has  been  re- 
corded in  only  10  out  of  80  cases.  Even  if  there  is  no  apparent  excess  of  fat, 
microscopically,  in  the  stool,  there  may  be  deficient  fat  splitting  of  ingested 
fats  into  fatty  acids  and  soaps,  and  an  excess  of  neutral  fat  may  be  found. 
1  Trans.  Assoc.  Amer.  Phys.,  1902,  xvii,  81. 


I034  DISEASES    OF    THE    STOMACH   AND   INTESTINES 

Azotorrhea  is  less  frequently  found. 

Suppuration,  as  already  noted,  may  occur  as  a  complication  of  pan- 
creatic calculus. 

The  hemorrhagic  tendency^  may  occur  with  pancreatic  calculi,  especially 
with  advanced  chronic  pancreatitis. 

Diagnosis. — Pancreatic  calculi  are  more  opaque  for  x-rays  than  are 
gall-stones,  and  this  fact  proves  of  value  for  diagnosis. 

The  analysis  of  the  calculus,  calcium  carbonate  or  phosphate,  when 
present  in  the  stools,  is  also  of  use.  Glycosuria,  when  present,  even  though 
temporarily  so,  is  significant,  and  also  deficient  splitting  of  the  ingested 
fats  into  fatty  acids  and  soaps.  Robson  and  Cammidge  set  much  store 
by  the  pancreatic  reaction  of  the  urine,  which  they  believe  usually  to  be 
present,  but  the  writer  beUeves  it  uncertain.  The  location  of  the  pain 
and  the  direction  of  its  radiation  in  some  cases  proves  of  service. 

Treatment. — ^Lazarus  recommends  that  secretion  be  increased  by  the 
administration  of  large  quantities  of  water,  and  especially  to  acidify  it 
with  carbonic  acid  gas  or  weak  acids.  Pancreatic  secretion  may  be 
increased  by  the  injection  hypodermically  of  pilocarpin,  >foo  grain 
(0.0006),  and  Eichhorst  reports  a  favorable  result.  This  method  may  be 
dangerous,  particularly  if  there  is  obstruction  in  the  duct. 

Possibly  prosecretin,  3  grains  (0.5),  which  is  less  active  and  a  normal 
excitant,  three  times  a  day,  might  be  of  service.  Morphin,  3^  to  ^-^ 
grain  (0.0075-0.0022),  may  be  administered  by  hypodermic  for  the  acute 
attacks  of  pain;  heat  should  be  applied  to  the  epigastrium,  and  shock  be 
treated  in  the  usual  method,  if  such  be  present.  A  hot  bath  is  useful, 
as  in  attacks  of  renal  or  biliary  colic. 

Surgery. — In  several  cases  pancreatic  calculi  have  been  successfully 
removed  by  operation  through  incision  in  the  duodenum  or,  preferably, 
by  pancreolithotomy. 

It  is  indicated  to  explore  the  gall-bladder  and  common  bile-duct 
and  remove  calculi,  if  present.  If  there  is  hemorrhage  from  the  gastro- 
intestinal tract  or  subcutaneous  or  nasal  hemorrhage,  and,  in  any  event 
for  several  days  before  operation  and  for  at  least  a  week  thereafter, 
calcium  lactate  should  be  administered  in  divided  doses,  60  to  90  grains 
(4.0-6.0)  per  day  by  mouth  or  by  rectum,  if  there  is  vomiting.  Hypo- 
dermic injection  of  normal  human  serum,  or  horse  serum  by  mouth,  may 
be  further  indicated  for  hemorrhage. 

^  Hemorrhage  from  the  stomach,  intestines  and  from  other  mucous  membranes  and 
also  into  the  skin  and  subcutaneous  tissues. 


CHAPTER  XLV 

CYSTS  OF  THE  PANCREAS— NEOPLASMS 
CYSTS 

Cysts  of  the  pancreas,  though  not  frequent,  must  be  considered  in 
the  diagnosis  of  cysts  of  the  abdomen,  since  they  occur  in  various  regions, 
and  may  simulate  other  diseases. 

About  173  cases  of  operation  on  cysts  of  the  pancreas  have  been 
recorded.  Hale  White  states  that  in  nearly  6000  autopsies  at  Guy's 
Hospital  from  1883  to  1894  only  four  cases  of  pancreatic  cyst  were  found, 
one  of  which  was  a  hydatid  cyst. 

The  simplest  classification  is  as  follows: 

1.  True  cysts  of  the  pancreas. 

2.  Pseudocysts. 

3.  Hydatid  cysts. 

I.  Among  the  true  cysts  we  have: 

(a)  Retention  cysts,  due  to  obstruction  of  the  outflow  of  the  pan- 
creatic secretion,  with  resulting  dilatation  of  the  ducts  of  the  acini. 

(b)  Proliferation  cysts,  or  cystic  neoplasms.  These  are  cystic  tumors, 
due  to  spontaneous  proliferation  of  the  epithelial  elements  of  the  gland, 
with  accumulation  of  fluid  in  the  cavities  which  are  so  formed.  They 
may  be  simple,  such  as  cystadenomata;  or  malignant,  cystic  epitheliomata 
or  carcinomata. 

(c)  Congenital  cystic  disease  of  the  pancreas  is  exceedingly  rare. 
Retention  Cysts. — Etiology. — Partial  or  intermittent  occlusion  of  the 

pancreatic  duct  favors  the  formation  of  retention  cysts  of  the  pancreas. 

The  outflow  of  pancreatic  secretion  may  be  interfered  with  by  ob- 
struction of  the  excretory  duct,  or  by  compression  from  without  and 
obstruction  within  it. 

Compression  of  the  pancreatic  ducts  by  tumors,  by  gall-stones,  or 
closure  by  a  pancreatic  calculus,  or  by  a  large  calculus  in  the  diverticulum 
of  Vater,  tumors  in  the  bile-passages  or  duodenum,  swollen  lymphatic 
glands  pressing  on  the  duct,  adhesions  or  intestinal  parasites  in  the  pan- 
creatic duct,  may  be  causes.  Frequently  no  cystic  formation  results,  but 
sometimes  cysts  are  found. 

Chronic  pancreatitis  is  believed  to  be  the  most  common  cause  of 
retention  cysts. 

Occlusion  of  the  ducts  is  followed  by  interlobular  pancreatitis,  which, 
when  far  advanced,  may  cause  diabetes  mellitus. 

Retention  cysts  are  frequently  quite  small,  and  may  not  cause  symp- 
toms. There  may  be  a  beaded  or  rosary-like  dilatation  of  the  pancfeatic 
duct,  which  has  been  described  as  "ranula  pancreatica,"  or  multiple  cysts 
of  small  size  containing  opaque  thick  fluid,  "acne  pancreatica,"  or  a 
single  cystic  dilatation  as  large  as  a  man's  fist. 

1035 


1036  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

They  are  occasionally  multiple — two  of  equal  size,  unilocular  or 
multilocular.  One  cyst  may  have  several  small  cysts  attached  to  its 
walls. 

When  a  cyst  enlarges  it  destroys  the  substance  of  the  gland,  and,  at  the 
same  time,  interstitial  inflammation  is  produced  in  the  adjacent  gland- 
tissue.  The  cyst  may  become  pedunculated.  Retention  cysts  of  large 
size  have  been  reported  containing  15  to  20  quarts  (liters)  of  fluid. 

The  wall  of  the  cyst  is  composed  of  dense  fibrous  tissue  with  few  cells, 
and  may  be  3  to  4  mm.  thick.  Occasionally  the  wall  is  thin.  Large 
blood-vessels  often  traverse  the  outer  surface. 

The  inner  surface  consists  of  an  epithelial  lining  of  a  single  layer  of 
cylindric  cells,  which  may  be  flattened  by  pressure.  It  is  sometimes 
smooth  and  shining,  and  free  from  epithelium. 

In  some  cases  the  cyst  lining  may  have  ridges  or  septa;  the  remains 
of  other  cysts  or  clotted  blood  may  be  found  therein  adherent  to  the 
surface.  Portions  of  pancreatic  tissue  are  sometimes  embedded  in  their 
walls. 

Proliferation  Cysts,  or  Cystic  Neoplasms  of  the  Pancreas. — Many  of 
these  tumors  are  on  the  border-line  between  proliferating  cystoma  and 
cystic  carcinoma,  and  only  the  subsequent  course  of  the  tumor  will  indi- 
cate to  which  class  it  belongs.  They  are  characterized  by  irregular 
gland-like  growths  below  the  epithelial  lining  of  the  cyst  and  by  the 
presence  of  papillary  projections  from  the  cyst  lining.  There  are  two 
types — the  cystadenoma  and  the  epitheliomata  cysticum. 

The  simple  proliferation  cyst  (cystadenoma)  is  usually  multilocular, 
has  a  lining  of  columnar  epithelium,  which  sometimes  dips  down  into  the 
wall  of  the  cyst,  and  at  times  covers  polypoid  masses,  which  projects  into 
its  cavity. 

These  cysts  are  more  common  in  the  tail  of  the  pancreas,  and  often 
their  contents  are  blood  stained. 

Rarely  cystic  tumors  of  the  pancreas  are  malignant  (the  cystic  epi- 
thelioma). Hartmann^  described  one  in  the  tail  of  the  pancreas  which 
was  accompanied  by  metastases  in  the  liver. 

Sotti,  under  the  name  of  adenocystoma  papilliferum,  described  a 
tumor  of  the  pancreas  with  metastases  in  the  lymphatic  glands  and  lungs. 

The  malignant  form  is  usually  multilocular,  with  patches  of  carcino- 
matous tissue  in  its  walls. 

In  some  cases  chocolate-colored  fluid  is  contained  in  the  cyst.  Met- 
astatic deposits  occur  in  the  liver,  pancreatic  glands,  duodenum,  and  in 
other  organs,  rendering  the  tumor  inoperable. 

Congenital  cystic  disease  of  the  pancreas  is  exceedingly  rare.  Robson 
and  Moynihan  refer  to  three  cases,  resembling  that  met  with  in  other 
organs. 

Hydatid  cysts  of  the  pancreas  seldom  occur  resembling  the  lesion  met 
with  in  the  liver.     Evacuation  and  drainage  are  indicated. 

Pseudocysts  of  the  Pancreas. — Pseudocysts  constitute  a  large  pro- 
portion of  cases  reported  as  pancreatic  cysts.  They  may  be  found  within 
the  substance  of  the  pancreas,  but  the  greatest  number  of  pseudocysts  are 

^  Cong,  franc  de  Chir.,  1891,  v,  618. 


CYSTS  OF  THE  PANCREAS — NEOPLASMS 


1037 


formed  in  contact  with  the  gland,  particularly  in  the  lesser  peritoneal 
cavity,  as  a  result  of  injury  to  the  pancreas. 

Blood  and  pancreatic  juice  escaping  into  the  lesser  cavity  set  up  a 
mild  form  of  peritonitis,  which  closes  the  foramen  of  Winslow  and  produces 
a  tumor  which  is  difficult  to  differentiate  from  a  true  cyst.  Enzymes 
similar  to  those  of  the  pancreatic  juice  have  been  found  in  traumatic  cysts. 
Fig.  423  is  shown  the  method  of  the  origin. 

Pseudocysts  within  the  pancreas  containing  blood  have  been  believed 
to  be  the  result  of  hemorrhage  into  the  organ. 

The  wall  of  these  cysts  is  formed  by  dense  connective  tissue.  There 
is  no  epithelial  lining  to  the  cyst,  but  this  does  not  always  determine  the 
nature  of  the  lesion  since  the  epithelial  lining  may  be  destroyed  by  the 
pancreatic  juice. 


Pancreas 


Lesser  peritoneal  sac 


Stomach 


Colon 


Small  intestiae 


Fig.  423. — Diagram  to  show  the  method  of  origin  of  a  pseudocyst  of  the  pancreas 

(Robson  and  Cammidge). 

Etiology. — In  33  out  of  1 1 7  cases  of  pancreatic  cyst,  Korte  has  found 
that  traumatism  to  the  abdomen  preceded  the  appearance  of  a  palpable 
tumor.     Lazarus  has  collected  eight  more  cases. 

Among  the  various  injuries  to  the  epigastric  region  are  the  kick  of  a 
horse  or  compression  between  car  buffers.  Indirect  force  may  produce 
it  also,  such  as  a  violent  fall,  by  tearing  the  pancreas. 

These  traumatic  pseudocysts  usually  contain  blood,  though  only  clear 
fluid  be  present. 

Hemorrhagic  necrosis  of  the  pancreas  may  be  the  direct  cause  of  pseudo- 
cysts. A  number  of  such  cases  have  been  reported,  the  patient  having 
recovered  from  the  attack  of  acute  pancreatitis,  with  the  subsequent 
appearance  of  the  cyst. 


1038  DISEASES   OF   THE    STOMACH   AND   INTESTINES 

Sex. — The  greater  portion  of  the  traumatic  pseudocysts  occur  in  males, 
who  are  most  exposed  to  injury,  while  true  cysts  occur  more  frequently  in 
females. 

Cystic  Contents. — The  fluid  in  the  pancreatic  cysts  and  pseudocysts 
may  furnish  little  evidence  as  to  their  origin.  Blood  is  generally  present. 
The  fluid  is  frequently  reddish  brown;  it  may  be  coffee-colored,  yellow, 
greenish,  milky,  black,  or  bright  red  from  recent  hemorrhage.  After 
absorption  of  the  blood,  traumatic  cysts  may  contain  clear  fluid.  The 
contents  are  sometimes  viscid,  more  or  less  turbid,  and  mucin  has  been 
demonstrated  therein. 

The  specific  gravity  varies  from  1.007  to  1.028,  and  the  reaction  is 
generally  alkaUne,  rarely  neutral,  and  still  more  rarely  acid.  Sugar  is 
seldom  met  with.  Albumin  is  present.  Under  the  microscope,  red  blood- 
cells,  fat-cells,  epithelial  cells,  crystals  of  fatty  acids,  leukocytes,  necrotic 
tissue  at  times,  at  times  cholesterin,  and,  rarely,  leucin  and  tyrosin  are 
present. 

One  or  more  of  the  pancreatic  enzymes  can  frequently  be  demonstrated 
in  these  cysts.  Proteolytic,  lipolytic,  and  diastatic  enzymes  have  been 
found  in  the  fluid  of  abdominal  cysts  which  did  not  originate  from  the 
pancreas,  and  cysts  of  tTie  pancreas  may  show  no  activity  of  these  enzymes. 
Nevertheless,  if  a  cyst  contains  fluid  which  can  digest  coagulated  egg- 
albumen  or  split  starch,  it  is  probable  that  it  originates  from  the  pancreas. 

Symptoms. — In  studying  the  symptoms  of  the  pancreatic  cyst  one 
must  consider  the  possible  cause  from  which  the  cyst  may  develop,  the 
general  symptoms,  both  subjective  and  objective,  the  physical  signs  of  the 
tumor,  and,  finally,  the  pressure  symptoms  which  may  result  from  its 
presence. 

There  may  be  a  history  of  previous  traumatism  in  the  epigastrium  or 
of  an  attack  of  hemorrhagic  necrosis  of  the  pa:ncreas,  subsequently  fol- 
lowed by  the  development  of  a  tumor,  or  of  previous  attacks  pointing  to 
pancreatic  calcuH,  or  disturbances  suggestive  of  a  chronic  pancreatitis. 

The  Rontgen  rays  may  be  of  service  in  determining  the  presence  or 
absence  of  pancreatic  calculi,  also  the  examination  of  the  stool.  The 
last  may  also  demonstrate  disturbance  of  the  pancreatic  functions. 

On  the  other  hand,  cases  do  occur  which  have  existed  for  a  long  time 
and  present  few  or  no  symptoms  except  the  presence  of  the  tumor. 

As  regards  general  symptoms,  pain  in  the  epigastrium  or  just  above 
the  umbilicus  may  be  present,  and  may  occur  even  when  the  cyst  is  not 
palpable.  There  may  be  colicky  paroxysms,  varying  in  location  and 
intensity,  sometimes  there  is  no  pain  whatever.  Vomiting  may  occur, 
associated  with  the  acute  attacks  or  pain,  or  the  cyst  may  be  bound  to  the 
stomach  by  adhesions  and  produce  gastric  disturbance.  Constipation  is 
usually  present.  Bulky  pale  motions  are  rare  and  only  occur  with 
advanced  pancreatitis.  The  cyst  may  compress  the  lumen  of  the  intes- 
tines and  produce  intestinal  obstruction.  Jaundice  does  not  occur  as 
frequently  with  pancreatitis  cyst  as  it  does  with  carcinoma,  because  the 
former  is  less  frequently  in  the  head  of  the  gland. 

In  some  cases  disturbances  of  digestion  referable  to  a  diminution  of 
the  flow  of  pancreatic  juice  into  the  intestines  occur.     Fitz  has  found  only 


CYSTS  OF  THE  PANCREAS — NEOPLASMS  IO39 

two  cases  of  steatorrhea  with  cyst  of  the  pancreas,  and  only  two  in  which 
there  were  undigested  muscle-fibers  in  the  feces.  These  last  conditions  show 
advanced  destruction  of  the  gland.     Glycosuria  is  associated  with  them. 

Glycosuria  and  diabetes  mellitus  follow  severe  chronic  inflammation 
of  the  pancreas,  which  last  is  produced  by  a  cyst  occluding  the  ducts. 
Diabetes  was  present  in  only  9  out  of  134  cases  which  were  collected  by 
Oser.     Alimentary  glycosuria  has  been  reported. 

Emaciation  is  a  frequent  symptom,  and  in  some  cases  cannot  apparently 
be  explained  as  due  to  disturbances  of  pancreatic  digestion.  The  patient 
frequently  rapidly  regains  weight  after  drainage  of  the  cystic  contents. 

Robson  and  Cammidge  report  marked  pancreatic  reaction  in  the  urine. 
The  writer  believes  this  of  no  value. 

Pressure  Symptoms. — Among  the  symptoms  due  to  pressure  of  the 
.cyst  are:  Dilatation  of  the  superficial  branches  of  the  portal  vein,  ascites 
from  pressure  on  the  portal  vein,  or  edema  of  the  lower  extremities  from 
pressure  on  the  inferior  vena  cava. 

In  two  cases  the  right  ureter  has  been  obstructed.  Dyspnea  may  result 
from  pressure  on  the  diaphragm  or  from  distention  of  the  abdominal 
cavity.     Rarely,  intestinal  obstruction  may  result  from  pressure. 

Physical  Signs  of  Pancreatic  Cysts. — The  cyst  is  usually  spheric  and 
the  surface  is  smooth.  It  may  be  as  large  as  a  human  head,  and  may  even 
fill  the  entire  abdominal  cavity  from  the  ensif orm  cartilage  to  the  symphysis. 
Usually  fluctuation  can  be  felt,  but  at  times  the  sac  is  so  tense  that  it 
appears  to  be  a  solid  growth. 

The  tumor  is  often  situated  in  the  middle  line  between  the  ensiform 
cartilage  and  the  umbilicus.  It  may  cause  a  round  protrusion  of  the 
abdominal  wall;  in  many  instances  the  greater  part  of  the  cyst  lies  to  the  left 
of  the  median  litie,  and  in  a  few  cases  it  was  found  on  the  right  side. 
Occasionally  cysts  have  extended  to  below  the  umbilicus. 

Usually  these  cysts  exhibit  little  mobility  unless  they  are  in  contact 
with  the  diaphragm,  in  which  case  they  move  with  respiration.  When 
they  are  situated  in  the  tail  of  the  pancreas  they  may  be  freely  movable. 
If  the  cyst  is  in  contact  with  the  aorta,  pulsation  may  be  transmitted,  but 
it  disappears  when  the  patient  is  in  the  knee-chest  position. 

The  relation  of  the  different  parts  of  the  pancreas  from  which  the  cyst 
originates  to  adjacent  organs  determines  the  physical  signs. 

The  relation  of  the  cyst  to  the  stomach  and  colon  can  be  defined  after 
artificial  distention  of  these  organs  with  carbonic  acid  gas  or  with  air. 
Korte  studied  133  cases  of  pancreatic  cyst  which  were  operated  upon, 
and  classified  the  positions  which  they  occupied. 

Pancreatic  cysts  usually  project  from  the  anterior  surface  of  the 
pancreas  into  the  lesser  peritoneal  cavity  and  push  the  stomach  upward. 
They  are  covered  by  the  gastrocolic  omentum  (Fig.  424). 

Small  cysts  lie  behind  the  stomach. 

Cases  have  been  reported  in  which  the  cyst  arises  from  the  upper  border 
of  the  pancreas,  and  makes  its  way  between  the  stomach  and  liver,  being 
covered  by  the  gastrohepatic  omentum  (Fig.  425). 

The  dulness  of  the  tumor  is  continuous  with  the  dulness  of  liver. 
Inflation  of  the  stomach  will  cover  the  dull  area  of  the  tumor. 


1 040 


DISEASES    OF   THE    STOMACH   AND   INTESTINES 


In  some  the  cyst  grows  between  the  two  layers  of  mesocolon,  and  the 
cyst  projects  upon  the  upper  surface  of  the  mesocolon  and  lies  between 
the  stomach  and  colon  (Fig.  426). 

Occasionally,  the  cyst  may  project  on  the  under  surface  of  the  meso- 
colon and  the  transverse  colon  lie  above  it  (Fig.  427)  or  the  colon  may 
cross  the  summit  of  the  cyst  (Fig.  428). 

The  cyst  may  pass  into  the  right  hypochondrium  and  simulate  an 
enlarged  gall-bladder,  or  right  renal,  or  suprarenal,  cyst.  It  may  make 
its  way  into  the  right  or  left  lumbar  region  and  simulate  a  cyst  of 
the  kidney;  or  it  may  pass  forward  to  the  right  and  beneath  the  hepatic 


Fig.  424. — A  cyst  projecting  from  the  ventral  surface  of  the  pancreas  into  the  bursa 
omentalis.  The  stomach  is  in  front  of  the  cyst  and  with  its  growth  is  pushed  upward; 
the  transverse  colon  is  below  it;  M,  stomach;  C,  transverse  colon;  P,  pancreas;  M.t., 
transverse  mesocolon. 


flexure  of  the  colon  and  resemble  a  tumor  of  the  kidney,  cecum,  or  ascend- 
ing colon.  In  some  instances  it  burrows  between  the  layers  of  the 
mesentery,  simulating  a  mesenteric  cyst,  or  may  pass  to  the  left  and 
resemble  a  left  renal  or  ovarian  cyst,  or  a  cyst  of  the  spleen  or  left  lobe  of 
the  liver.  It  has  also  simulated  a  tumor  of  the  descending  colon  or  of  the 
small  intestine. 

Accumulation  of  fluid  in  the  lesser  peritoneal  cavity  (pseudocyst) 
may  closely  resemble  the  true  pancreatic  cyst.  A  cyst  may  pass  through 
the  foramen  of  Winslow  into  the  general  peritoneal  cavity,  or  may  rupture 
into  the  peritoneal  cavity  as  the  result  of  injury  produced  by  a  blow  or  fall. 

The  spontaneous  disappearance  of  a  cyst  without  intraperitoneal 


CYSTS  OF  THE  PANCREAS — NEOPLASMS 


IO4I 


P.C 


Fig.  425. — Pancreatic  cyst  between  liver   and  stomach   (Robson  and   Cammidge): 
L,  Liver;  P.C,  pancreatic  cyst;  S,  stomach;  C,  colon. 


P.C 


Fig.  426. — Pancreatic  cyst  between  stomach  and  colon  (Robson   and   Cammidge): 
L,  Liver;  S,  Stomach;  P.  C,  pancreatic  cyst;  C,  colon. 


66 


I042  ■    DISEASES   OF   THE    STOMACH   AND    INTESTINES 


P.C 


Fig.  427. — Pancreatic  cyst  below  the  transverse  colon:  Z,,  Liver;  5,  Stomach;  C,  colon: 
P.  C,  pancreatic  cyst  (Robson  and  Cammidge). 


Fig.  43S. — A  pancreatic  cyst  (T)  which  has  penetrated  between  the  folds  of  the 
transverse  mesocolon  (M.t.)  and  projects  equally  upon  the  upper  and  lower  surface. 
The  stomach  is  above  the  cyst  and  the  transverse  colon  crosses  it. 


CYSTS  OF  THE  PANCREAS — NEOPLASMS  IO43 

rupture  has  been  reported  in  association  with  diarrhea.  The  contents 
probably  entered  the  intestine.  BulP  and  Parsons  report  such  cases. 
Diarrhea  occurred  at  the  time  of  the  disappearance.  Possibly  one  of  the 
pancreatic  ducts  communicated  with  the  cyst. 

Diagnosis. — A  round  fluctuating  tumor  lying  in  the  epigastrium^ 
especially  when  tlie  greater  part  is  to  the  left  of  the  median  line,  is  suggestive 
of  a  pancreatic  cyst.  Most  frequently  the  cyst  lies  between  the  stomach 
and  transverse  colon.  The  stomach  usually  partially  covers  it.  Even 
when  the  cyst  occupies  the  more  uncommon  position  between  the  stomach 
and  liver,  percussion  of  the  cyst  while  inflating  the  stomach  is  of  value, 
since  tumor  gradually  becomes  covered  as  the  stomach  distends.  Cysts 
of  the  liver  and  spleen  or  a  distended  gall-bladder  remain  superficial,  and 
are  not  pushed  back  and  covered  Ijy  the  distending  stomach. 

Mesenteric  cysts  usually  lie  near  the  umbilicus  and  are  freely  movable. 
Pancreatic  cysts  may  appear  in  this  region,  but  generally  there  is  no 
mobility.     At  times  the  pancreatic  cyst  may  extend  as  far  as  the  pelvis. 

The  history  of  the  cyst  as  first  commencing  in  the  epigastrium  may  be 
of  service;  also  inflation  of  the  colon  may  aid  in  the  determination  of  its 
relations,  and  bimanual  examination  of  the  vagina  and  rectum  may  ex- 
clude its  connection  with  the  uterus  and  ovaries. 

The  disappearance  of  the  tumor  is  more  suggestive  of  hydronephrosis. 

Exploratory  aspiration  of  the  cystic  tumor  the  writer  believes  danger- 
ous. It  may  damage  the  viscera  or  cause  extravasation  of  the  cystic 
contents. 

The  history  is  of  great  value  in  many  cases. 

The  Cammidge  reaction  may  be  tested,  though  the  writer  has  no  faith 
in  the  procedure.  The  pancreatic  functions  should  be  investigated  and 
the  urine  examined  for  sugar.  These  factors  are  an  aid  to  diagnosis. 
The  contents  of  the  cyst  should  be  tested  for  enzymes  after  evacuation  by 
operation. 

Treatment. — Surgical  treatment  is  alone  of  service.  Aspiration  is 
dangerous  for  the  purpose  of  diagnosis.  Incision  and  drainage  is  the 
operation  of  choice;  extirpation  is  more  dangerous,  and  in  many  cases  is 
impossible.  Description  of  the  surgical  procedures  has  no  place  in  this 
volume. 

It  is  recommended  to  administer  a  diet  to  lessen  the  flow  of  pancreatic 
juice,  thus,  bread  and  milk,  with  the  administration  of  small  doses  of 
sodium  carbonate,  5  to  10  grains  (0.32-0.65)  t.i.d.,  are  excellent.  Others 
advise  a  diabetic  diet  and  the  use  of  the  same  drug. 

As  in  all  cases  of  pancreatic  disease,  chlorid  or,  preferably,  lactate  of 
calcium,  i  dram  (4.0)  in  divided  doses,  should  be  administered  for  a  week 
before  and  after  operation.  In  the  latter  event  it  can  be  given  for  a  time 
by  rectum  by  enema  or  proctoclysis.  Human  serum  may  be  used  by 
hypodermic,  and  the  calcium  salts,  60  to  90  grains  (4.0-6.0)  daily,  by 
mouth,  if  hemorrhage  occur  at  any  time  during  the  course  of  the  disease. 

Mayo  Robson  records  160  cases  of  pancreatic  cyst  which  have  been 
operated.  Of  these,  there  were  20  deaths  subsequent  to  operation,  and 
8  deaths  later  from  diabetes  or  other  complications.  Of  138  cases  treated 
'  N.  Y!  Med.  Jour.,  1887,  xlvi,  376. 


I044  DISEASES   OF   THE   STOMACH   AND   INTESTINES 

by  incision  and  drainage,  death  occurred  in  i6.  Among  15  cases  in  whom 
complete  excision  was  practised,  3  died.  Partial  excision  in  7  cases  re- 
sulted in  I  death.  Korte  collected  102  cases,  of  which  loi  were  treated 
by  incision  and  drainage,  with  only  4  deaths. 


NEOPLASMS 

Tumors  of  the  pancreas  are  not  a  very  common  occurrence,  and  are 
most  frequently  of  a  maUgnant  nature.  The  solid  growths  met  with 
in  the  pancreas  are  carcinoma,  sarcoma,  adenoma,  and  lymphoma.  Segre,^ 
in  11,472  autopsies,  reports  127  cases  of  carcinoma  and  two  of  sarcoma. 
Benign  tumors  are  less  common. 

Carcinoma 

Carcinoma  is  the  most  common  of  the  new  growths  found  in  the 
pancreas.  Probably  some  cases  reported  as  cancer  of  the  liver  were  cases 
of  primary  carcinoma  of  the  pancreas,  with  secondary  nodules  in  the  liver. 
Formerly  cancer  was  considered  the  most  common  lesion  aflFecting  the 
pancreas,  but  chronic  interstitial  pancreatitis  was  undoubtedly  mistaken 
for  it  in  many  instances. 

Age. — Carcinoma  usually  occurs  after  forty  years  of  age,  though 
a  case  in  a  patient  aged  thirty-two  has  been  reported,  and  rarely  it  has 
occurred  in  childhood,  Bourke^  reports  a  case  in  a  patient  twenty-two 
years  old. 

Sex. — Carcinoma  is  more  frequent  in  males.  In  108  cases^  there 
were  69  in  men  and  39  in  women. 

Situation  of  Tumor. — Carcinoma  is  most  frequently  situated  in  the 
head  of  the  gland.  It  was  involved  in  about  62  per  cent,  of  the  cases 
recorded:  in  5.5  per  cent,  the  tail  was  affected;  in  3.5  per  cent.,  the  body; 
and  there  was  a  diffuse  growth  in  29  per  cent.  The  duct  of  Wirsung  was 
obliterated  in  55  out  of  66  cases,  and  dilated  beyond  the  point  of  stricture 
in  about  one- third  of  the  cases.  Among  57  cases  collected  by  Segre,  the 
tumor  was  situated  in  the  head  of  the  gland  in  35  cases;  in  the  body, 
twice;  in  the  tail,  once,  and  the  entire  gland  was  affected  in  19 cases. 
Out  of  113  cases  reported  by  Miraillie,  primary  carcinoma  of  the  head  of 
the  pancreas  was  present  in  82. 

Oser  states  that  there  is  secondary  carcinomatous  involvement  of 
the  pancreas  in  more  than  10  per  cent,  of  cases  of  primary  carcinoma  of 
the  stomach.  Metastasis  also  takes  place  from  carcinoma  of  other 
organs. 

Frequency. — Out  of  53,000  autopsies,  Roswell  Park  reports  226 
cases  of  primary  malignant  disease  of  the  pancreas.  Secondary  growths 
of  the  pancreas  are  much  more  common.  Eppinger  reports,  in  13 14 
autopsies,  19  cases  of  cancerous  involvement  of  the  pancreas.  Only  two 
of  these  were  primary  cancer  of  the- pancreas.  There  were  308  cancers  in 
various  organs. 

1  Annual  Univ.  de  Med.  et  Chir.,  1888. 

2  Journal  A.  M.  A.,  Mar.  14,  1914. 

'  Miraillie,  Gaz.  des  Hop.,  1893,  Ixvi,  889. 


CYSTS  OF  THE  PANCREAS — NEOPLASMS  IO45 

Morbid  Anatomy. — Carcinoma  of  the  pancreas  begins  either  in  the 
glandular  epithelium  or  in  the  cells  of  the  excretory  ducts.  In  the 
former  instance  it  is  of  the  spheroid  type,  and  in  the  latter  usually 
columnar. 

Spheroid-celled  carcinoma  is  the  more  common  and  usually  of  the 
scirrhous  type,  and  is  composed  of  firm,  fibrous  nodules.  Occasion- 
ally it  is  encephaloid,  soft,  and  cellular.  Colloid  carcinoma  has  been 
observed. 

Roux*  described  a  cystic  epithelioma,  and  Sotti  a  malignant  adenocys- 
toma with  metastases  in  the  lymphatic  glands  and  lungs. 

Secondary  deposits  are  most  common  in  the  liver,  but  may  be  found 
anywhere. 

A  variety  of  carcinoma  characterized  by  great  irregularity  in  the  size 
and  shape  of  its  cells,  and  believed  to  Originate  in  the  island  of  Langer- 
hans,  has  been  described  by  Hiller  and  Goodall.  Secondary  interstitial 
pancreatitis  is  present  in  some  cases,  and  occasionally  small  cysts  may 
occur. 

Carcinomatous  growths  of  the  pancreas  are  usually  of  small  size  (5 
to  10  cm.  in  diameter), but  occasionally  they  are  quite  large.  When  the 
tumor  invades  adjacent  organs,  such  as  the  liver,  bile-passages,  stomach, 
and  duodenum,  the  origin  of  the  primary  growth  may  be  in  doubt. 

Effects  of  Adhesions  and  P*ressure. — Adhesions  may  be  formed  be- 
tween the  tumor  and  adjacent  organs,  and  various  lesions  may  result  from 
pressure.  Thus,  occlusion  of  the  duodenum  or  pylorus  may  cause  dilata- 
tion of  the  stomach,  or  the  stomach  may  be  compressed  against  the 
abdominal  wall,  or  compression  of  the  transverse  colon  may  cause  in- 
testinal obstruction. 

Obstruction  of  the  bile-duct  with  dilatation  of  the  gall-bladder  is  common. 
Pressure  on  the  left  ureter  may  cause  hydronephrosis,  or  on  the  portal 
vein  may  produce  ascites. 

Edema  of  the  lower  extremities  may  follow  pressure  on  the  vena  cava. 
The  tumor  tissue  may  invade  the  stomach  or  duodenum,  and  perforation 
of  these  viscera  may  occur.  The  pancreas  may  be  secondarily  invaded 
from  the  stomach  or  duodenum. 

Symptoms. — The  symptoms  of  carcinoma  of  the  pancreas  are  modified 
by  the  position  of  the  growth  and  by  the  degree  of  chronic  pancreatitis 
which  is  sometimes  associated  with  it. 

In  the  largest  percentage  of  cases  of  cancer  of  the  pancreas  the  head  of 
the  gland  is  involved. 

The  earliest  symptoms  are  rapid  loss  of  weight  and  strength,  with 
loss  of  appetite,  discomfort  after  eating,  and  distaste  for  meat.  Nausea 
and  vomiting  may  occur;  constipation  is  most  frequently  present,  though 
occasionally  there  may  be  diarrhea.  In  the  earlier  stages  the  movements 
may  be  normal.  Cachexia  is  rapid,  jaundice  soon  appears,  and  is  pro- 
gressive. The  skin  may  become  dark,  almost  black  in  color,  or  in  some 
cases  like  the  yellow  color  from  gall-stones;  the  gall-bladder  enlarges  and 
is  readily  recognizable  and  the  liver  swells.  There  are  intense  prostration 
and  weakness.  Pain,  particularly  in  the  early  stages,  is  at  times  absent. 
'  Cancer  et  Kystes  du  Pancreas,  Paris,  1891. 


1046  DISEASES    OF    THE    STOMACH    AND   INTESTINES 

The  writer  has  recently  seen  a  large  carcinoma  of  the  outer  third  of  the 
body,  with  no  pain  whatever.  It  may,  when  the  tumor  rapidly  increases, 
be  quite  intense  from  pressure  on  the  celiac  ganglion  or  on  adjacent  nerve- 
trunks,  and  may  radiate  to  the  back  or  shoulders.  Occasionally,  there 
may  be  colicky  pain  due  to  occlusion  of  the  pancreatic  duct,  which  may 
resemble  the  colic  of  pancreatic  lithiasis  or  colicky  pains  from  pressure 
on  the  common  bile-duct  resembling  biliary  colic.  The  stool  is  pale  in 
color  after  the  appearance  of  the  jaundice  and  bile  is  found  in  the  urine. 
The  obstruction  of  the  common  bile-duct  is  usually  complete  and  the 
feces  contain  no  stercobilin. 

With  scirrhous  cancer  of  the  head  of  the  pancreas  often  the  tumor 
cannot  be  felt;  in  about  one-fourth  or  one-fifth  of  the  cases  the  cancerous 
mass  is  palpable,  usually  in  the  epigastric  region,  more  rarely  in  the  right 
or  left  hypochondrium.  Usually  the  mass  is  immovable,  unless  lying  in 
the  tail  of  the  pancreas.  Occasionally  it  moves  with  respiration  or  trans- 
mits the  pulsation  of  the  aorta.  There  is  frequently  absence  of  free  HCl 
in  the  stomach  contents,  as  may  occur  with  cancer  situated  in  other  organs. 
This  finding  does  not,  therefore,  always  determine  involvement  of  the 
stomach.  Excessive  vomiting  with  dilatation  of  the  stomach  may  result 
from  carcinomatous  involvement  of  the  pyloric  end  of  that  organ  or  of  the 
duodenum. 

Adhesions  may  cause  similar  symptoms.  Occasionally,  there  may 
be  no  enlargement  of  the  gall-bladder  if  the  cystic  or  hepatic  duct  alone 
are  involved  by  the  growth,  or  if  the  gall-bladder  be  obliterated  by  previous 
inflammation.  In  some  instances  steatorrhea  or  disturbances  in  the 
ratio  of  neutral  fats  and  combined  fatty  acids  are  present,  and  rarely  un- 
digested muscle-fibers  are  found  in  the  stool.  Bulky  stools  may  occa- 
sionally be  present.  Alimentary  glycosuria  has  been  observed,  and 
diabetes  mellitus  when  there  is  great  involvement  of  the  pancreas,  and 
particularly  with  a  complicating  interacinar  pancreatitis.  If  the  tumor 
lies  near  tlie  tail  of  the  pancreas^  there  is  no  jaundice.  In  some  cases  where 
the  body  or  tail  of  the  organ  are  involved  there  may  be  tenderness  at 
Robson's  point  as  with  chronic  pancreatitis. 

Intestinal  obstruction  (chronic),  even  merging  into  the  acute,  may 
result  from  pressure  on  the  transverse  colon  or  ileum.  The  writer  re- 
cently has  been  a  case  of  chronic  intestinal  obstruction  caused  by  pressure 
from  carcinoma  of  the  outer  third  of  the  body  of  the  pancreas.  There 
was  no  jaundice.  H.  Haubold  found  this  condition  on  operation.  Ascites, 
swelling  of  the  spleen,  hemorrhoids,  dropsy  of  the  lower  limbs,  and  hy- 
dronephrosis may  result  from  pressure. 

Perforation  of  adjacent  viscera  may  occur.  Chylous  ascites  due  to 
perforation  or  rupture  of  the  thoracic  duct  has  been  reported. 

There  is  frequently  a  marked  hemorrhagic  tendency,  particularly  in 
the  cases  of  cancer  of  the  head  of  the  pancreas  with  jaundice. 

Hemorrhage  may  occur  from  the  nose,  mouth,  stomach,  intestines, 
and  subcutaneously.     Persistent  bleeding  or  oozing  is  liable  to  occur, 
both  at  and  subsequent  to  operation.     Cammidge  states  the  C-reaction 
(Cammidge)  is  present  in  about  25  per  cent,  of  all  cases  and  the  A-reaction" 
in  most  cases.     The  writer  is  skeptical  as  to  the  value  of  these  reactions. 


CYSTS  OF  THE  PANCREAS — NEOPLASMS  1 04 7 

Examination  of  the  stool,  the  urine,  and  testing  the  pancreatic  functions 
are  an  aid  to  diagnosis. 

Diagnosis. — Rapid  emaciation,  progressive  weakness,  increasing  ane- 
mia, jaundice  becoming  very  intense,  dilatation  of  the  gall-bladder, 
and  epigastric  tumor  (not  always  present)  are  significant  of  carcinoma 
of  the  head  of  the  pancreas;  glycosuria  and,  occasionally,  steatorrhea  are 
confirmatory  when  present.  The  patient  is  usually  over  forty.  The 
course  is  very  rapid,  not  over  a  year,  and  after  the  onset  of  jaundice,  only 
six  to  eight  months;  on  distending  the  stomach  with  air  or  carbonic  acid 
gas,  the  tumor,  if  present,  disappears.  The  temperature  is  subnormal. 
Symptoms  from  pressure,  such  as  anasarca,  etc.,  occur  in  some  cases. 
With  cancer  of  the  outer  part  of  the  body  of  the  pancreas  there  are  no  jaun- 
dice and  no  dilatation  of  gall-bladder. 

Loewis'  Test. — The  instillation  of  3  or  4  drops  of  adrenalin  chlorid 
(1:1000)  into  the  conjunctival  sac  causes  mydriasis  in  patients  sufifer- 
ing  from  pancreatic  disease.  This  test  depends  on  the  diminution  or 
absence  of  the  island  of  Langerhans  hormone,  so  that  there  is  increased 
excitability  of  the  sympathetic  system  due  to  an  excess  of  the  antag- 
onistic adrenal  hormone.  When  this  does  not  take  place  following  the 
instillation,  it  is  presumed  that  the  pancreatic  hormone  is  present. 

Crohn^  holds  that  the  absence  of  bile,  or  pancreatic  ferments  on  duo- 
denal aspiration  determines  the  diagnosis  of  new  growth  in  this  region. 

Cholelithiasis. — There  is  a  preliminary  history  of  gall-stone  attacks; 
the  jaundice  comes  on  after  an  attack  of  pain  and  is  sudden.  Remissions 
of  jaundice  sometimes  occur;  the  impacted  calculi  may  produce  intense 
jaundice. 

Some  bile  usually  escapes  past  the  gall-stones  into  the  intestines,  and 
stercobilin  is  present  in  the  stools.  The  bile  is  likely  to  become  infected, 
and  ague-like  paroxysms  occur  with  an  irregular  temperature.  There  is 
no  distended  gall-bladder,  but  there  is  a  rigid  right  rectus  muscle.  There 
is  frequently  a  tender  point  above  and  to  the  right  of  the  umbilicus,  and 
there  may  be  pain  which  passes  to  the  midscapular  region  or  beneath  the 
right  shoulder-blade. 

As  a  rule,  the  liver  is  not  enlarged  with  cholelithiasis,  though  it  may 
be  enlarged  and  tender  in  an  acute  attack.     This  history  is  long. 

Chronic  Pancreatitis. — With  chronic  pancreatitis  the  history  is  long, 
the  jaundice  is,  as  a  rule,  not  complete,  and  may  be  slight  or  absent; 
infection  of  the  pancreatic  duct  and  infective  cholangitis  are  often  present, 
as  shown  by  occasional  chills  and  temperature.  The  loss  of  flesh  is  less 
marked.  Only  after  a  long  period  (much  longer  than  one  can  live  with 
cancer)  may  there  be  anasarca  or  enlargement  of  the  abdominal  veins. 
There  is  a  history  of  attacks  of  pain  and  local  tenderness  may  be 
present.  At  operation  for  gall-stones,  when  enlargement  of  the  head  of 
the  pancreas  can  be  felt  in  a  patient  before  middle  life,  or  there  are 
adhesions  of  long  standing,  and  the  history  is  long,  the  disease  is  apt  to 
be  chronic  pancreatitis.  Someimes  enlarged  glands  are  found  with  this 
condition,  but  they  are  apt  to  be  discrete,  while  with  cancer  they  are 
usually  confluent.  The  loss  of  flesh  and  strength  is  less  marked,  and 
'  Amer.  Jour.  Med.  Science,  Dec,  1914 


1048  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

the  gall-bladder  is  seldom  distended  though  rarely  it  is  enlarged.  Anemia 
is  less  marked. 

Cancer  of  the  common  bile-duct  is  rare  and  is  usually  associated 
with  gall-stones.  If  the  papilla  .is  involved,  the  symptoms  cannot  be 
distinguished  from  cancer  of  the  head  of  the  pancreas.  K  the  cancer  lie 
above  the  opening  of  the  pancreatic  duct  into  the  ampulla,  the  pancreatic 
functions  will  not  be  so  markedly  disturbed  and  the  loss  of  flesh  will 
not  be  so  rapid. 

Tumor. — Tumor  of  the  pancreas  is  usually  less  movable  than  tumors 
of  the  pylorus  or  colon,  and  its  position  does  not  change,  as  do  tumors  of 
these  organs  when  distended  with  carbonic  acid  gas  or  air.  It  is  found 
in  about  one-fifth  of  the  cases,  and  lies  in  the  epigastrium  usually,  though 
occasionally  in  the  right  or  left  hypochondrium.  Carcinoma  of  the  pan- 
creas can  be  at  times  determined  by  inflation  of  the  stomach  and  colon, 
since  the  pancreatic  tumor  becomes  covered  by  the  distended  organs. 

Cancer  of  the  Liver. — With  cancer  of  the  liver  the  jaundice  is  absent 
or  less  intense  and  the  liver  soon  enlarges.  Irregular  nodules  can  be  felt 
on  the  surface  and  edges.  Cachexia  is  marked.  Syphilis  can  be  excluded 
by  the  Wassermann  or  Noguchi's  tests. 

Cancer  of  the  Pylorus. — Cancer  of  the  pylorus*  can  be  diagnosed  by  the 
usual  methods,  but  sometimes  both  pancreas  and  stomach  are  involved. 
Cammidge  sets  great  store  on  his  urinary  test  as  an  aid  to  diagnosis,  but 
the  writer  has  not  been  impressed  as  to  its  value. 

Treatment. — In  the  earlier  stages,  when  doubt  arises  as  to  whether 
the  condition  be  one  of  chronic  pancreatitis  or  carcinoma,  exploration  is 
indicated,  with  drainage  of  the  gall-bladder,  if  such  be  required. 

Obstruction  of  the  bowel  or  pyloric  orifice  of  the  stomach,  when  oc- 
curring, must  necessarily  be  relieved  to  prolong  life.  When  the  carcinoma 
involves  the  head  of  the  pancreas,  life  is  not  prolonged  by  operation  to 
any  extent,  and  the  writer  believes  operative  procedure  to  be  useless. 
If  the  growth  involve  the  tail  of  the  gland  and  there  are  no  metastases 
and  only  a  few  enlarged  glands,  a  partial  pancreatectomy  may  be  indicated. 
So  far  the  results  of  operation  for  carcinoma  of  the  pancreas  have  been 
exceedingly  bad,  and  life  does  not  seem  to  be  prolonged  to  any  extent. 

Medical  treatment  must  be  symptomatic,  morphin  for  pain,  if  such 
occur.  Chlorid  or  lactate  of  calcium,  60  to  90  grains  (4.0-6.0)  per  day  or 
human  serum  injections  for  hemorrhage;  holadin,  pancreon  tablets, 
lic^uor  pancreaticus,  or  one  of  the  preparations  of  the  pancreatic  ferments 
to  aid  digestion,  secretin  gr.  i  t.i.d.  or  prosecretion  gr.  3  t.i.d.,  to  stimu- 
late pancreatic  secretion  and  the  usual  treatment  of  symptoms.  The 
bowels  should  be  properly  regulated. 

Sarcoma  of  the  Pancreas 

Primary  sarcoma  of  the  pancreas  is  a  very  rare  disease.  Out  of 
11,492  autopsies  Segre  found  this  condition  only  twice,  and  Hale  White 
only  one  case  in  6708  autopsies.  Kakels^  collected  21  cases,  among  which 
10  only  were  believed  to  be  primary. 

^  The  a;-rays  are  of  value  in  determining  malignancy  of  the  pylorus,  by  demon- 
strating the  presence  of  deformity,  or  obstruction. 

*Amer.  Jour.  Med.  Sci.,  1902,  cxxiii,  471. 


CYSTS  OF  THE  PANCREAS — NEOPLASMS  IO49 

Fibrosarcoma,  medullary  sarcoma,  mixed-cell  sarcoma,  lympho- 
sarcoma, spindle-celled  sarcoma,  and  angiosarcoma  have  been  described. 
Sarcomatous  degeneration  of  an  ecchinococcus  cysts  of  the  tail  of  the 
pancreas  has  also  been  reported  successfully  removed  by  operation. 

Age  of  the  Patient. — The  age  of  the  patients  vary  from  four  to  seventy 
years.     The  period  of  life  may,  therefore,  not  be  significant  for  diagnosis. 

S3miptoms. — Rapid  loss  of  flesh  and  strength,  and  the  symptoms  de- 
scribed under  Carcinoma  may  occur. 

Secondary  sarcoma  of  the  pancreas  is  not  uncommon.  It  occurs  most 
frequently  as  a  lymphosarcoma  arising  from  a  primary  sarcoma  of  the 
duodenum,  mediastinum,  or  abdominal  lymph-glands.  Secondary  mel- 
anotic sarcoma  of  the  pancreas  has  also  been  described,  the  primary 
growth  being  situated  in  the  eye. 

Diagnosis. — The  general  course  of  the  disease  resembles  carcinoma  of 
the  pancreas,  though  the  tumor  may  grow  more  rapidly. 

Treatment. — The  medical  treatment  should  be  symptomatic.  Sur- 
gical procedure  results  unfavorably,  though  exploration  for  diagnosis  may 
be  necessary.     Coley's  erysipelas  toxins  may  be  tried. 

Adenoma  of  the  Pancreas 

Cystic  adenomata  have  been  described.  Simple  adenoma  may  origf 
inate  from  the  epithelium  of  the  duct,  the  gland  acini,  or  an  island  o- 
Langerhans.  Fibro-adenoma  has  been  reported.  Nicholls  describes  a 
tumor  consisting  of  a  stroma  of  connective  tissue  arranged  in  irregular 
alveoli  which  contained  cells  of  a  glandular  type,  probably  arising  from 
an  island  of  Langerhans.  One  case  of  fibro-adenoma  of  the  head  of  the 
pancreas  has  been  reported  by  Biondi,^  which  was  palpable  and  caused 
jaundice.  Recovery  followed  removal.  Small  tawny,  yellow  tumors  have 
been  described  which  histologically  resembled  an  island  of  Langerhans. 

Symptoms. — No  characteristic  symptoms  are  produced  except  from 
pressure  on  the  ducts  or  adjacent  organs,  and  the  presence  of  a  palpable 
tumor. 

Treatment. — Attempt  should  be  made  to  extirpate  the  tumor  by 
operation. 

Lymphadenoma. — ^Lymphadenoma  of  the  pancreas  is  extremely  rare. 
Only  two  cases  are  referred  to,  which  were  met  with  in  patients  who  died 
from  Hodgkin's  disease. 

'  Riforma  Med.,  1896,  ii,  97. 


CHAPTER  XL VI 

DEGENERATIVE  CHANGES  OF  THE  PANCREAS    THE  PANCREAS 
AND  DIABETES— HEMOCHROMATOSIS 

DEGENERATIVE  CHANGES  OF  THE  PANCREAS 

Degenerative  changes  occurring  in  the  Uver,  kidneys,  and  other 
parenchymatous  organs  may  also  afifect  the  pancreas.  Like  other  organs, 
the  pancreas  may  diminish  in  size  and  weight  as  the  years  advance,  or 
theTsame  condition  may  result  from  chronic  diseases  or  from  marasmus; 
senile  atrophy  is  accompanied  in  many  instances  by  sclerotic  changes  in 
the  blood-vessels,  or  it  may  be  the  result  of  malnutrition,  such  as  occurs 
with  chronic  wasting  diseases. 

Atrophy  of  the  pancreas  is  met  with  in  a  considerable  number  of  dia- 
betics, and  the  cause  of  both  conditions  is  usually  a  chronic  interstitial 
pancreatitis. 

Opie  shows  there  are  cases  of  diabetes  in  which  the  pancreas  were 
markedly  diminished  in  size,  though  no  changes  could  be  observed  in  the 
structure  of  the  glands.  Possibly  this  condition  is  congenital,  and  at  some 
period  of  life  the  pancreas  is  so  small  that  it  cannot  fulfil  the  demands  made 
upon  it,  so  diabetes  results.  Another  condition  believed  to  be  due  to 
congenital  pancreatic  deficiency  was  first  described  by  Byron  Bramwell  as 
"pancreatic  infantilism."  Secondary  atrophic  changes  may  occur  in 
the  pancreas  as  the  result  of  pressure  from  aneurysm,  and  new  growths  or 
chronic  interstitial  inflammation  which  accompanies  pancreatic  calculi, 
pancreatic  cysts,  hemorrhage,  or  abscess. 

The  pancreas  may  undergo  fatty,  hyaline,  or  amyloid  degeneration, 
and  focal  necrosis. 

Fatty  Degeneration. — Etiology. — The  prolonged  use  of  alcohol  usually 
produces  an  excess  of  fat  or  fatty  degeneration  in  the  islands  of  Langer- 
hans.  Fatty  degeneration  is  caused  most  frequently  by  inflammation 
of  the  pancreas,  but  it  may  occur  with  infectious  diseases,  toxemias,  or 
from  poisoning  by  phosphorus  or  the  mineral  acids,  or  be  associated  with 
pancreatic  lithiasis. 

In  extreme  cases  the  entire  organ  may  be  transformed  into  a  mass 
of  fatty  tissue,  and  the  pancreas  is  yellow  or  yellowish  white,  soft,  and 
larger  than  normal.  On  section  the  gland  is  lobulated  and  consists  of 
masses  of  fat,  separated  by  strands  of  fibrous  tissue  in  which  the  remains 
of  the  larger  ducts  and  remnants  of  the  gland  structure  are  embedded. 
The  epithelium  contains  numerous  fat  globules  and  the  interstitial  tissue 
is  edematous. 

Amyloid  Degeneration. — Amyloid  degeneration  occurs  with  a  similar 
condition  in  other  organs,  and  is  associated  with  the  same  causes  as  the 
cachectic  state,  particularly  when  due  to  prolonged  suppuration;  tuber- 

1050 


THE    PANCREAS    AND   DIABETES  105I 

culous  bone  diseases;  less  frequently  pulmonary  tuberculosis;  tertiary 
syphilis;  the  cancerous  cachexia;  rickets;  protracted  convalescence  from 
acute  infectious  diseases;  and  chronic  enterocolitis.  It  does  not  attain 
the  severity  such  as  is  seen  in  the  liver,  spleen,  and  kidneys. 

The  application  of  iodin  to  the  pancreas  turns  the  area  of  amyloid 
degeneration  a  dark  brown. 

Metachromatic  stains,  such  as  gentian  violet  or  methyl  green,  may 
be  used  to  demonstrate  the  amyloid  condition. 

Hyaline  Degeneration. — This  form  of  degeneration  exhibits  a  special 
tendency  to  attack  the  inter  acinar  islands  of  Langerhans,  and  generally  leaves 
the  secreting  parenchyma  unaffected.  Diabetes  is  particularly  associated 
with  it. 

Pathology. — There  is  first  an  increase  in  size  of  the  cells  of  the  islands 
of  Langerhans  and  an  alteration  of  their  protoplasm.  The  nuclei  disap- 
pear with  the  death  of  the  cells  and  the  cell  protoplasm  finally  becomes 
homogeneous.  Small  masses  of  hyaline  matter  fuse  together  and  form 
larger  collections. 

The  hyaline  material  may  occupy  nearly  tne  entire  area  of  the  island 
and  only  a  few  epithelial  cells  be  present.  The  island  appears  as  a 
circumscribed  hyaline  structure  of  homogeneous  material  in  a  series  of 
broken,  twisted  columns,  between  which  lie  capillary  walls.  The  lumen 
of  the  blood-vessels  is  patent  and  red  blood-corpuscles  are  visible  between 
the  hyaline  masses. 

It  is  usually  accompanied  by  chronic  interacinar  pancreatitis,  though 
the  increase  in  interstitial  tissue  is  sometimes  slight.  Arteriosclerosis 
has  been  present  in  a  number  of  cases.  The  hyaline  material  stains 
deeply  with  eosin,  picric  acid,  and  other  acid  dyes,  and  shows  little  aflSnity 
to  nuclear  stains.  It  does  not  give  the  amyloid  reaction.  Similar  hyaline 
degeneration  is  not  present  in  the  other  organs. 

Focal  Necrosis.— In  a  case  of  diabetes  reported  by  Opie  there  was 
present  a  lesion  of  the  pancreas,  resembling  the  focal  coagulation  necrosis 
observed  in  the  liver  in  typhoid  fever  and  like  infections.  It  affected  both 
the  islands  of  Langerhans  and  also  the  parenchyma.  The  process  is 
acute,  but  there  is  a  commencing  chronic  proliferation  of  interstitial  tissue 
replacing  the  defects  caused  by  destruction  of  the  cells.  Focal  necrosis 
of  the  pancreas  has  been  found  in  a  number  of  cases  associated  with  lobar 
pneumonia  and  other  infections. 

THE  PANCREAS  AND  DIABETES 

The  writer  has  already  referred  to  the  fact  that  the  islands  of  Langer- 
hans produce  an  internal  secretion  which  influences  carbohydrate  metabo- 
lism, and  disease  of  the  islands  will  produce  diabetes  mellitus.  Opie* 
reports  findings  in  288  cases  of  diabetes  mellitus:  interacinar  pancreatitis 
in  43.4  per  cent.  (125  cases);  interlobular  pancreatitis  (13  cases) ;  atrophy 
(65  cases);  lipomatosis  (18  cases);  while  calculi,  cyst,  carcinoma,  and  focal 
necrosis  were  found  in  a  few  others.  There  were  a  few  cases  with  lesions 
of  the  islands  of  Langerhans,  such  as  hyaline  degeneration,  sclerosis, 

'  Diseases  of  the  Pancreas. 


1052  DISEASES    OF    THE    STOMACH    AND    INTESTINES 

adenoma,  and  hypertrophy — with  normal  parenchyma.  There  were  34 
cases  of  diabetes  with  a  normal  pancreas  and  five  cases  with  normal 
parenchyma,  but  the  islands  reduced  in  number. 

CeciP  found  lesions  of  the  islands  of  Langerhans  in  79  (88  per  cent.) 
of  90  cases  of  diabetes. 

The  changes  which  destroy  the  islands  of  Langerhans,  especially 
interacinar  pancreatitis  and  hyaline  degeneration,  are  almost  constantly 
accompanied  by  diabetes,  while  the  lesions  which  destroy  the  parenchyma 
and  invade  the  islands  of  Langerhans  only  when  the  lesion  is  far  advanced, 
such  as  in  the  case  of  interlobular  pancreatitis,  pancreatic  calculi,  and 
carcinoma,  are  usually  not  accompanied  by  diabetes.  Acute  lesions  of  the 
pancreas,  such  as  acute  pancreatitis  (hemorrhagic  necrosis)  or  suppuration, 
rarely  cause  glycosuria,  since  usually  sufficiently  healthy  parenchyma 
remains  to  prevent  its  onset. 

In  a  small  percentage  of  cases  of  diabetes  mellitus  (6.6  per  cent.) 
of  those  reported  by  Cecil  no  abnormality  of  the  pancreas  was  found. 
Changes  in  the  central  nervous  system,  the  liver,  and  the  kidneys  have 
been  followed  by  glycosuria,  and  even  by  diabetes,  and  diabetes  has  also 
accompanied  exophthalmic  goiter  and  acromegaly. 

Arteriosclerosis  is  present  in  a  large  number  of  diabetics  due  to  its 
production  of  interstitial  pancreatitis.  The  close  association  between 
cirrhosis  of  the  liver  and  diabetes  has  often  been  observed,  the  latter 
in  the  majority  of  cases  the  result  of  chronic  interstitial  pancreatitis, 
both  the  cirrhosis  and  pancreatitis  usually  being  the  result  of  the  same 
factor,  alcohol,  for  example. 

Higgins^  and  Ogden  found  glycosuria  in  9.3  per  cent,  of  212  cases  of 
traumatism  affecting  the  head,  and  in  21.9  per  cent,  out  of  45  cases  of 
fractured  skull.  Diabetes  is  occasionally  associated  with  tabes  or  with 
multiple  sclerosis  or  tumors  of  the  medulla. 

A  renal  diabetes  has  been  suspected,  and  Klemperer^  has  described 
a  case  of  diabetes  associated  with  nephritis. 

Among  other  conditions  with  which  diabetes  has  been  associated  are 
myxedema,  disease  of  the  adrenals,  and  acromegaly.  Glycosuria  has 
been  observed  to  follow  the  use  of  thyroid  extract,  and  it  has  been  sug- 
gested that  glycosuria  occurring  with  exophthalmic  goiter  is  referable  to 
abnormal  activity  of  the  thyroid. 

In  many  cases,  diabetes,  which  is  associated  with  arteriosclerosis, 
cirrhosis  of  the  liver,  hemochromatosis.  Graves'  disease,  and  acromegaly, 
is  secondary  to  a  pancreatitis  which  accompanies  these  diseases. 

In  about  12  per  cent,  of  all  cases,  diabetes  is  unaccompanied  by  a  lesion 
of  the  islands  of  Langerhans,  and  diabetes  with  a  normal  pancreas  usually 
occurs  during  the  early  period  of  life,  most  frequently  before  the  age  of 
thirty. 

Diabetes  which  occurs  during  middle  life  and  later  can  generally  be 
referred  to  a  lesion  of  the  pancreas.  Interacinar  pancreatitis  is  responsible 
for  about  two-thirds  of  the  cases  of  diabetes  after  forty  years  of  age. 
Though  alimentary  glycosuria  may  occur  without  pancreatic  disease, 

1  Ibid. 

2  Boston  Med.  and  Surg.  Jour.,  1895,  cxxxii,  197. 
*  Berliner  Klin.  Woch.,  1896,  xxxiii.  571. 


HEMOCHROMATOSIS  IO53 

with  hysteria  and  other  neuroses,  from  the  administration  of  excessive 
sugar  or  starchy  products,  etc.,  its  persistence  suggests  the  existence  of  a 
pancreatic  lesion. 

HEMOCHROMATOSIS 

Von  Recklinghausen,^  under  the  term  "hemochromatosis,"  describes 
a  condition  of  pigmentation  affecting  various  organs.  He  believes  the 
brown  pigment  is  derived  from  the  hemoglobin  of  the  blood.  There  is 
an  iron-containing  pigment,  "hemosiderin,"  in  the  epithelial  cells  of  the 
various  glands,  chiefly  the  liver  and  pancreas.  There  is  also  an  iron- 
free  pigment,  "hemofusan,"  in  the  muscle-cells  of  the  gastro-intestinal 
tract,  also  in  the  muscle-cells  of  the  blood  and  lymph-vessels,  and  connec- 
tive-tissue cells.     Cirrhosis  of  the  liver  is  associated  with  the  pigmentation. 

Bronzed  Diabetes. — Hanot-  and  Chaufifard  describe  a  closely  related 
condition  of  diabetes  mellitus  associated  with  hypertrophic  cirrhosis  of 
the  liver  and  bronze-like  pigmentation  of  the  skin,  "diabete  bronze." 

The  diabetes  is  rapidly  fatal.  Associated  with  it  is  an  hypertrophic 
cirrhosis  of  the  liver,  and  bronzing  of  the  skin  is  present  in  the  majority  of 
cases. 

Etiology. — The  pigment  deposited  in  the  liver  and  other  organs  is 
undoubtedly  derived  from  the  hemoglobin  in  the  blood.  In  many  cases 
it  has  been  accompanied  by  conditions  causing  an  active  destruction  of 
the  red  blood-cells,  such  as  morbus  maculosus,  the  hemorrhagic  dia- 
thesis, etc. 

It  is  believed  that  phagocytosis  of  the  red  blood-corpuscles  by  the 
parenchymatous  cells  of  various  organs  takes  part  in  the  process.  Chronic 
interstitial  pancreatitis  of  the  interacinar  variety  has  been  reported  in 
these  cases,  as  well  as  hypertrophic  cirrhosis  of  the  liver. 

'Tagebl.  d.  62  Versamml.  deutsch.  Naturforsher  v.  Aertze  in  Heidelberg,  1889,  324. 
-Rev.  de  Med.,  1882,  ii,  385. 


INDEX 


Abderhaldex  test,    Van    Slyke's    modi- 
fication of,  in  gastric  cancer,  341 
Abderhalden  and  Schittenhelm's  method 

of  testing  for  trypsin,  978 
Abdomen,  anatomic  landmarks,  65 
auscultation,  73 
barrel-shaped,  67 

in  chronic  intestinal  obstruction,  884 
examination,  65 
in  hot  baths,  69 
technic,  66 
inflammatory  lesions  of,  diverticulitis 

and,  differentiation,  856 
inspection,  66 
palpation,  67 

bimanual  method,  69 
Boston's  double  method,  69 
method  of,  67 
reinforced,  68 
percussion  of,  70 

protrusion  in  intestinal  diseases,  516 
topographic  anatomy,  65,  74 
Abdominal  cavity,  sounds  in,  73 

examination,  preparation  of  patient,  66 
muscles,  functions,  444 
pressure  in  gastroptosis,  increase,  464 
soreness  in  amebic  dysentery,  683 
support  in  gastroptosis,  462 
wall,  superficial  reflexes  of,  in  appjendi- 
citis,  813 
Aberrant  pancreas,  959 
Abscess  in  acute  appendicitis,  816 
in  diverticulitis,  853,  854 
ischiorectal,  798 
liver,  in  amebic  dysentery,  675 
diagnosis,  676 
physical  signs,  676 
symptoms,  676 
treatment,  692 
of  rectum,  797 

superficial,  797 
of   stomach,    246.     See    also   Gastritis, 

phlcgnwnotts. 
pelvic,  798 

subphrenic,  terminations  of,  288 
Absorption  from  intestines,  41 

protein,  573 
Acetic  acid  in  gastric  contents,  150 
Acetonuria  in  pancreatic  disease,  987 
intestinal,  500 
classification,  580 
Achlorhydria,  383 
diagnosis,  386 
diet  in,  385 
etiology,  383 


Achlorhydria,  haemorrhagica  gastrica,  269 

bacteriologj-,  271 

blood  in,  272 

cancer  and,  differentiation,  273 

chronic  erosions  and,  differentia- 
tion, 273 

chronic  gastritis  and,  differentia- 
tion, 253,  273 

diagnosis,  272 

diet  in,  2  74 

duodenal  ulcer  and,  differentiation, 

751 
etiology,  269 
gastric  analysis  in,  271 

ulcer  and,  differentiation,  272 
lavage  in,  275 

microscopic  examination,  270 
morbid  anatomy,  270 
occult  blood  in,  272 
prognosis,  273 
symptoms,  272 
treatment,  274 
medication  in,  385,  386 
treatment,  386 
Acholic  feces,  536 
Achylia  gastrica,  262 
absorption  in,  265 
age  in,  263 
cancer  of  stomach  and,  differentiation, 

266 
chronic  gastritis  and,  differentiation,  253 
course,  265 
diagnosis,  265,  266 
differential,  239 
diet  in,  194,  267 
etiology,  263 

gastralgia  and,  differentiation,  477 
gastric  analysis  in,  265 
gastric  cancer  and,  differentiation,  349 
history,  262 

intestinal  irrigation  in,  269 
morbid  anatomy,  263 
motor  function  in,  265 
prognosis,  265 

putrefaction  in,  treatment,  269 
symptoms,  263 
temporary,  262 
treatment,  266,  628 
pancreatic,  1005 
Acid  gastritis,  248 

duodenal   ulcer  and,   differentiation, 

751 
poisoning,  antidotes  for,  245 
Acidosis,  intestinal,  580 
classification,  580 


105s 


1056 


INDEX 


Acini  of  pancreas,  965 
Acne  pancreatica,  1035 

rosacea,  stomach  functions  in,  506 

simplex,  stomach  functions  in,  506 
Adenocarcinoma  of  stomach,  324 
Adenocystoma  papilliferum  of  pancreas, 

1036 
Adenoma  of  intestines,  779 

of  pancreas,  1049 
Adhesions,  colonic,  641 
Adnexa,  uterine.  Head's  zones  for,  833 
Aerophagia,  485,  487,  585 
Agar-agar  in  constipation,  621 
Air  inflation  of  intestines,  529 
of  stomach,  96 

swallowing,  585 
Akoria,  472 
Akoric  dyspepsia,  591 
Albumin,  absorption  of,  42 

in  feces,  535 
Alcohol  as  food,  189 

in  typhoid  fever,  716 

poisoning,  antidotes  for,  245 
Algesimeter,  Boas',  91 
Alimentary  gastrosuccorrhea,  396 
Alimentation,  duodenal,  190 

rectal,  191 
Alkalis     in     gastrosuccorrhea     continua 

chronica,  395 
Allingham's   operation   for   hemorrhoids, 

793. 
Allotriophagia,  472 
Aloes  in  constipation,  622 
Aloin  test  for  occult  blood,  161 
Amebae,  920 
Amebic  appendicitis,  681 

dysentery,  668.     See     also     Dysentery, 
amebic. 
Amebiosis,     intestinal,     668.      See     also 

Dysentery,  amebic. 
Amoeba  dysenteriae,  668 

encysted,  670 
Ampulla  of  Vater,  958 

variations,  960 
Amyloid  degeneration  of  pancreas,  1050 
Amylopsin,  39,  971 
examination  for,  977 
in  gastric  contents,  158 
Amyxorrhoea  gastrica,  280 
Anadenia  ventriculi,  249,  250,  262.     See 

also  Achylia  gastrica. 
Anchylostoma  duodenale,  941.     See    also 

Uncinariasis. 
Anematose,  Fairchild's,  191 
Anemia,   grave,   in   carcinoma   ventriculi 
without  palpable  tumor,  345 
in  gastric  cancer,  330 

treatment,  303 
in  uncinariasis,  945 
miners', '940 

stomach  functions  in,  503 
Anesthesia  of  rectum,  903 
Aneurysm  of  celiac  axis,  cancer  of  pylorus 
and,  differentiation,  347 
stomach  functions  in,  504 
Angioma  of  intestines,  780 
Anguillata  intestinalis,  948 


Anguillata  stercoralis,  948 
Angulations,  colonic,  641 
Angustatio  ventriculi,  437 
Ankylostoma  duodenale,  940 
Annular  pancreas,  959 
Anorexia  in  cancer  of  stomach,  329 
nervosa,  472 
transitory,  472 
Antidotes  for  poisoning,  245 
Antimony  poisoning,  antidotes  for,  245 
Antiperistaltic    restlessness    of    stomach, 

481 
Antitryptic  reaction  of  blood  in    gastric 

cancer,  339 
Antityphoid  vaccination,  707 

in  childhood,  707 
Antrum   cardiacum,  437 
Anuria  in  acute  ectasy  of  stomach,  410 
Anus,  fissure  of,  in  hemorrhoids,  796 
hygiene  of,  in  hemorrhoids,   787 
Apepsinia,  151 

Appendices  epiploicae  of  large  intestine,  29 
Appendicitis,  801 
acute,  abscess  in,  816 
black  vomit  in,  815 
diagnosis,  825 
diet  in,  836 

fecal  accumulation  in,  836 
fulminating  type,  817 
hyperinosis  in,  818 
indications  for  operation,  837 
in  infants  and  children,  811 
Lanz's  point  in,  812 
lavage  in,  836 
leukocytosis  in,  818 
McBurney's  point  in,  812 
Meltzer's  method  of  palpation  in,  814 
Morris'  point  in,  812 
muscular  rigidity  in,  811 
pain  in,  811 
percussion  in,  815 
rectal  examination  in,  815 
remote  effects,  821 
superficial  reflexes  of  abdominal  walls 

in,  813 
symptoms,  810 
temperature  in,  815 
tenderness  on  pressure  in,  8ii 
treatment,  835 
tumefaction  in,  816 
tumor  in,  815 
age  and,  805 
amebic,  681 
bacteria  causing,  802 
Blumberg's  sign  in,  813 
bowels  in,  815 
catarrhal,  acute,  805 
simple  acute,  806 
chronic,  801,  805,  822 

Bastedo's  method  of  testing  for,  814 
blood-clotting  time,  823 
diagnosis,  825 

x-T&y,  82  s 
diet  in,  836 
duodenal   ulcer   and,  differentiation, 

750 
Edebohls'  palpation  in,  823 


INDEX 


1057 


Appendicitis,  classification,  809 
claudicans,  822 
constipation  as  cause  of,  803 
diagnosis,  differential,  826 
diet  in,  836 
diffuse  acute,  805 
etiology,  802 

foreign  bodies  as  cause,  804 
gangrenous,  805,  808 
gastro-intestinal   symptoms   in,   815 
Head's  zones  in  diagnosis,  828 
intestinal  parasites  as  cause,  803 
myalgia  and,  differentiation,  827 
non-suppurative  acute,  805,  807 
obliterative,  806 
F>erforative,  808 
perforation  in  simple  duodenal  ulcer 
and,  differentiation,  744 
prognosis,  834,  835 
protective,  808,  809,  824 
purulent,  805,  807 
Rovsing- Chase  method  of  palpation  in, 

814 
sex  and,  805 
suppurative,  805 

acute,  807 
syncongestive,  809 
treatment,  835 
vaginal  examination  in,  815 
varieties,  805 

with  extrinsic  infection,  809 
with  intrinsic  infection,  809 
Appendicostomy  in  amebic  dysentery,  692 
Appendicular  colic,  811 
Appendix,  vermiform,  29 
blood-supply,  802 
cancer  of,  776 

primary,  776 
fibroid  degeneration,  809 
harmful  involution,  808,  824 
Head's  zones  in  affections  of,  833 
inflammation,  801 
intussusception,  870 
palpation,  811 
peculiarities,  802 
position,  801 
Appetite,   disturbance   of,   in   pancreatic 
diseases,  998 
juice,  35 

perversion  of,  472 
Arsenic  in  gastric  cancer,  358 
poisoning,  antidotes  for,  245 
Arterial  hemorrhoids,  783 
Arteries  of  cecum,  31 
of  colon,  31 
of  rectum,  31 
of  stomach,  20 
Arteriosclerosis,  stomach  functions  in,  506 

visceral,  588 
Arthritis  deformans,  stomach  functions  in, 

SOS  ,     . 
Ascaris  lumbricoides,  935 
diagnosis,  937 

intestinal  obstruction  by,  differentia- 
tion, 877 
migration,  936 
symptoms,  936 
67 


Ascaris  lumbricoides,  treatment,  937 

mystax,  938 
Aspirating  bulb,  Boas',  140 
tube,  139 
Ewald's,  139 
Aspiration,  intermittent,  fractional  study 
of  gastric  digestion  by,  137 
of  gastric  contents,  139 
Boas'  bulb  for,  140 
Boas'  method,  141 
Ewald-Boas  expression  method,  141 
Ewald's  tube  for,  139 
Kemp's  method,  142 
position  of  patient  and  operator, 
141 
Asthma,  dyspeptic,  499 

treatment,  500 
Atonia    gastrica,     399,     442.     See    also 

Gasiroptosis. 
Atonic  constipation,  611 
ectasy  of  stomach,  416 
Atony  of  stomach,  398,  485 
acute,  398 
in  pneumonia,  407 
treatment,  399 
chronic,  399 
diet  in,  400 
electricity  in,  401 
etiology,  399 
medication  in,  400 
physical  examination,  399 
prognosis,  400 
symptoms,  399 
treatment,  400,  401 
vibratory  massage  in,  400 
of  third  degree,  442.     See  also  Gasirop- 
tosis. 
with  hyperchlorhydria,  375 
Atrophic    gastritis,    249,    262.     See    also 

Achy  Ha  gastrica. 
Atrophy  of  gastric  mucosa,  250,  262.     See 
also  Achylia  gastrica. 
of  mucosa  in  chronic  enteritis,  653 
of  stomach,  250,  262.     See  also  Achylia 
gastrica. 
Auerbach's  plexus,  24 
Auscultation  in  intestinal  disease,  527 
of  abdomen,  73 
of  esophagus,  5 1 
Auscultatory  inflation  of  colon,  527 
percussion  in  intestinal  diseases,  526 
of  liver,  77 
of  stomach,  92 

scratch  method,  94,  95 
Autodigestion  of  pancreas,  971 
Autogenous  vaccines  in  typhoid  fever,  718 
Auto-intoxication,  571 
hydrogen  sulphid,  583 
in  constipation,  615 
Autolysin  treatment  of  gastric  cancer,  359 
Auto-massage  in  constipation,  619 
Autonomin,  893 
Aversion  to  food,  472 
Awl-tail,  938 
Azotorrhea,  984 

in  pancreatic  diseases,  999 
Azoturia  in  pancreatic  disease,  987 


I058 


INDEX 


Bacillary    dysentery,    692.     See    also 

Dysentefy,  bacillary. 
Bacilluria  in  typhoid  fever,  treatment,  7 1 7 
Bacillus  bifidus,  40 

Boas-Oppler  in  feces  in  gastric  cancer, 
342 
in  gastric  cancer,  338 
contents,  166 
coli,  40 

as  cause  of  wound  infection,  601 
infections,  as  cause  of  cholecystitis, 

599 
as  cause  of  choroiditis,  600 
as  cause  of  intra-abdominal  tumors, 

600 
as  cause  of  pelvic  exudate,  600 
diagnosis,  607 
general,  601 
method,  595 
of  kidneys,  594,  596 

in  chronic  interstitial  nephritis, 

599  .  . 
in  pyelitis,  598 
in  typhoid  fever,  598 
reaction  of  urine  in,  596,  607 
subphrenic  abscess  from,  602 
symptoms,  596 
treatment,  607 
types,  595 
dysenteriae,  693 
enteritidis,  706 
fsecalis  alcaligenes,  706 
lactis  aerogenes,  40,  41 
paratyphoid,  706 
paratyphosus,  718 
tubercle   in   feces   in   intestinal    ulcer, 

761 
t3T3hosus,  700 

distribution  in  body,  701 
outside  body,  701 
Bacteria  in  gastric  juice,  34 
in  mouth,  34 
in  small  intestine,  34 
in  stomach,  34 
of  intestine,  40 
Balantidium  coli,  921 
diarrhea  from,  923 
treatment,  924 
Balloon  man,  593 
Ballottement,  suprahepatic,  78 
Banti's  disease,   duodenal  ulcer  and,  dif- 
ferentiation, 752 
Bassler's  method  of  drainage  in  ectasy  of 
stomach,  412 
stomach  electrode,  218 
Bastedo's  method  of  testing  for  chronic 

appendicitis,  814 
Baths  in  obesity,  918 

in  typhoid  fever,  712 
Bath-tub,  portable,  713 
Beans,  cooking  of,  187 

protein  in,  187 
Beef  extracts,   effect  on  flow  of  gastric 
juice,  35 
tapeworm,  926 
Beef -juice,  188 
Beef-tea,  188 


Belching,  487 

in  chronic  gastritis,   treatment,   259 

nervous,  487 
Belt,  Kilmer's,  231-233,  234 

Rose's  adhesive  plaster,  226,  227 

rosewater  adhesive,  230,  234 
Benedict's    effervescent    test    for    gastric 

acidity,  374 
Benzidin  test  for  blood  in  gastric  contents 
and  stool,  159 
paper,  159 
Beyea's  operation  for  gastroptosis,  467 
Bile,  function  of,  38 

in  gastric  contents,  158 

in  vomit,  157 
Bile-ducts,  common,  anatomic  variations, 

960 
Bile-pigment,  acute  enteritis  and,  648 

examination  for,  976 

in  feces,  536 

sublimate  test  for,  549 
Bilharzia  haematobia,  931 
Bilharziasis,  931 

treatment,  934 
Biliary  acids  in  feces,  536 

colic,  hyperchlorhydria  and,  differentia- 
tion, 376 
Bilinuria  in  pancreatic  diseases,  987 
Bismuth  in  acute  enteritis,  650 

in  bacillary  dysentery,  697 

in  chronic  enteritis,  662 

subnitrate  in  a;-ray  examination  of  in- 
testines, 528 
Bite  block  for  esophagoscopy,  102 
Bladder  in  typhoid  fever,  702 
Blenorrhoea  intestinalis,  657 
Blood,  antitryptic  reaction  of,  in   cancer, 

339 
coagulation,  in  pancreatic  diseases,  992 
diarrhea  from  irritants  in,  626 
examination  in  simple  duodenal  ulcer, 

739 
fluke,  930 
in  achlorhydria  haeraorrhagica  gastrica, 

272 
in  acute  appendicitis,  818 
in  cancer  of  stomach,  330 
in  chronic  pancreatitis,  1025 
in  feces,  533,  535 

benzidin  test  for,  159 
in  intestinal  ulcer,  761 
in  gastric  cancer,  338 
contents,  159 

benzidin  test  for,  159 
ulcer,  286 
in  pancreatic  disease,  091,  998 
in  typhoid  fever,  705 
in  vomit,  157 
occult,  in  hiTJerchlorhydria,  376 

test  for,  160 
Trichinella  spiralis  in,  951 
vomiting  of,  in  pancreatic  diseases,  997 
Blood-clotting   time  in  chronic  appendi- 
citis, 823 
Blood-vessels  of  intestines,  diseases  of,  763 
of  islands  of  Langerhans,  967 
of  stomach,  20 


INDEX 


1059 


Blumberg's  sign  in  appendicitis,  813 
Boas'  algesimeter,  91 

aspirating  bulb,  140 

method  of  aspiration  of  gastric  contents, 

.141  . 

point  in  abdominal  palpation,  68 
test-breakfast,  137 
test  for  free  hydrochloric  acid,  144 
for  lactic  acid,  149 
Boas-Ewald  expression  method  of  aspi- 
rating gastric  contents,  141 
test-breakfast,  137 
Boas  and  Moerner's  test  for  free  h>'dro- 

chloric  acid,  153 
Boas-Oppler  bacilli  in  feces  in  gastric  can- 
cer, 342 
cancer,  338 
contents,  166 
Bone-marrow  in  typhoid  fever,  702 
Bonninger's  diagnosis  of  gastric  ulcer,  289 
Boston's  method  of  double  palpation,  69 
Bothriocephalus  cordatus,  928 

latus,  924,  927 
Botulism,  582 
Bougie,  cylindric,  524 

soft  rectal,  524 
Brand  treatment  of  typhoid,  712 
Brewer's  point,  87 
Brill's    disease,    720.     See   also    Typhus, 

mild  etidcmic. 
Bronchoscopy,  thimble  gag  or  bite  block 

for,  102 
Bronzed  diabetes,  1053 
Broths,  soy,  180 
Brunner's  glands,  27 
Brunning's  modification  of  Killian's  eso- 

phagoscope,  103,  104 
Bubbling  sounds  of  stomach,  97 
Bulimia,  470 

treatment,  471 
Bullet  wounds  of  pancreas,  1002 
Bunches,  943 

Cachexia,  diverticula  of  intestines  and, 
847 
in  gastric  cancer,  330 
Calcium  oxalate  in  urine  in  pancreatic 

diseases,  988 
Calculi  in  feces,  539 
pancreatic,  103 1 
age  and,  1032 
diagnosis,  1034 

Rontgen  raj',  1032 
etiology,  1033 
in  feces,  539 
jaundice  in,  1033 
occurrence,  1032 
pain  in,  1033 
pathology,  1032 
symptoms,  1033 
treatment,  1034 

surgical,  1034  * 

Calomel  in  acute  enteritis,  649 
Calorie,  172 
^     large,  172 
small,  172 
table,  Chittenden's,  175 


Calorie,  value  of  food,  172 
determination,  183 
of  protein,  173 
Cammidge  reaction  in  chronic  pancreatitis 
1026 
pancreatic,  988 
Cancer  atrophicans,  325 
of  appendix,  primary,  776 
of  body  of  stomach,  335 
of  cardia,  333 

dysphagia  in,  333 
esophageal  examination  in,  333 
physical  examination  in  333 
spasm  of  esophagus  in,  334 
of  colon,  cancer  of  pancreas  and,  differ- 
entiation, 1048 
of  duodenum,  772 
of  esophagus,  63 
early  diagnosis,  64 
symptoms,  63 
treatment,  64 
of  gall-bladder,  gastric  cancer  and,  dif- 
ferentiation, 349 
,     of  intestines,  767 
benign,  779 
colic  in,  774 
constipation  in,  774 
course,  777 
diagnosis,  777 

by  Rontgen  rays,  777 
differential,  775 
•  diet  in,  778 
etiology,  767 
feces  in,  770,  775 
morbid  anatomy,  768 
mobility  of  tumor  in,  771 
pain  in,  774 
prognosis,  777 
pus  in  feces  in,  775 
situation,  768 
symptoms,  770 

due  to  position,  772 
general,  770 
local,  774 
treatment,  777 
tumor  in,  775 
of  liver,  cancer   of  pancreas  and,  dif- 
ferentiation, 1048 
chronic  pancreatitis  and,  differentia- 
tion, 1027 
of  pancreas,  age  and,  104.1 

cancer  of  colon  and,  differentiation, 
1048 
of  liver  and,  differentiation,  1048 
of  pylorus  and,  differentiation,  1048 
cholelithiasis     and,     differentiation, 

t  ^°47 

:  chronic     pancreatitis     and,     differ- 
entiation, 1047 

diagnosis,  1047 

effects  of  adhesions  and  pressure,  1045 

frequency,  1044 

hemorrhage  in,  1046 

intestinal  obstruction  in,  1046 

morbid  anatomy,  1045 

obstruction  of  bile-ducts  with  dilata- 
tion of  gall-bladder  in,  1045 


io6o 


INDEX 


Cancer  of  pancreas,  pain  in,  1045 

sex  and,  1044 

situation,  1044 

•symptoms,  1045 

treatment,  1048 
of  pylorus,  125,  334 

aneurysm  of  celiac  axis  and,  differ- 
entiation, 347 

cancer  of  pancreas  and,  differentia- 
tion, 1048 
of  rectum,  776 

hemorrhoids  and,  differentiation,  786 

treatment,  786 
of  small  intestine,  774 
of  stomach,  320 

achlorhydria  haemorrhagica   gastrica 
and,  differentiation,  273 

achylia  gastrica  and,  differentiation, 
266.  349 

adhesion?  and,  differentiation,  350 

age  and,  320 

anemia  in,  330 

anorexia  in,  329 

anticancer  globulins  in,  359 

antitryptic  reaction  of  blood  in,  339 

arsenic  in,  358 

autolysin  treatment,  359 

benign  stenosis   and,  differentiation, 
348 

blood  m,  330,  338 

Boas-Oppler  bacilli  in,  338 
in  feces  in,  342 

cachexia  in,  330 

care  of  bowels  in,  363 

chronic  gastritis,  and,  differentiation, 

P53-  349 
classification  of  cases,  328 
colloid,  325 
coma  in,  332 
condurango  in,  358 
constipation  in,  332 
dangers  of  non-radical  operation,  323 
diagnosis,  338,  344 

differential,  344 

laboratory,  335 

Rontgen  rays  in,  342 
diagnostic  points,  348 
diet  in,  193,  355 
drugs  for,  358 
duration,  350 
edema  in,  332 
engrafted  on  ulcer,  347 
enlarged    lymph-glands    and,    differ- 
entiation, 349 
etiology,  321 

exploratory  laparotomy  in,  352 
exudates  and,  differentiation,  350 
fibrous,  324 

fluoroscopy  for  determination  of,  1 29 
frequency,  320 

gall-bladder  cancer  and,  differentia- 
tion, 349 
gastralgia  and,  differentiation,  477 
gastric    cancer    and,    differentiation, 

349 
contents  in,  335 
ulcer  and,  differentiation,  348 


Cancer  of  stomach,  gastritis  and,  322 
gastro-enterostomy  for,  355 
gastrostomy  for,  355 
glycyltr>'ptophan  test  for,  338 
grave  anemia  in,  pernicious  anemia 

and,  differentiation,  345 
hemolysis   as  diagnostic  method  in, 

340 
hemorrhage  in,  329 
heredity  and,  321 
hydrochloric  add  in,  336 
inflation  in,  331 

injections  of  cancer  residue  in,  359 
inspection,  330 
lactic  acid  in,  337 
leukocytosis  in,  330 
location,  326 
loss  of  appetite  in,  329 
loss  of  weight  in,  330 
Mayo's  partial  gastrectomy  for,  353, 

354 

medullary,  324 

mesenteric  growths  and,  differentia- 
tion, 350 

metastases  in,  326,  332 

methylene  blue  in,  359 

morbid  anatomy,  324 

multiple  neuritis  in,  332 

nervous  dyspepsia  and,   differentia- 
tion, 497 

pain  in,  328 

palliative  operation,  355 

palpation  in,  331 

percussion  in,  331 

perforation  in,  326,  332 

peritoneal  growths  and,  differentia- 
tion, 350 

prognosis,  350 

pus  in,  338 

race  and,  321 

radical  operation,  353 

radiologic  findings  in,  344 

rectal  examination  in,  338 

respiratory  motility  in,  331 

Rontgen-ray  diagnosis  of,  125 
filling  defects  in,  1 26 

Salomen's  test  in,  341 

scirrhous,  324 

sclerosis  and,  differentiation,  345 

secondary  changes  in  mucous  mem- 
brane, 325 

sex  and,  321 

silica  metabolism  in,  341 

skin  reaction  in,  340 

Smithies'  percussion  sign  in,  331 

sodium  iodid  in,  358 

symptoms,  327 

due  to  location,  333 
general,  327 

syphilis  and,  differentiation,  345 

syphilitic  cirrhosis  of  liver  and,  dif- 
fentiation,  346 
stenosis  of  pylorus  and,  differentia- 
tion, 346 

temperature  in,  332 

test-breakfast  in,  336 

tetany  in,  332 


INDEX 


1061 


Cancer  of  stomach,  thiosinamin  in,  358 
thrombosis  in,  332 
thymus  extract  in,  361 
thyroid  extract  in,  361 
transillumination  in,  332 
traumatism  in  etiology,  321 
treatment,  351 

autolysin,  359 

drug,  358 

medical,  355 

of  constipation  in,  363 

of  diarrhea  in,  363 

of  ectasia  in,  362 

of  hemorrhage  in,  362 

of  pain  in,  362 

of  vomiting  in,  362 

radium,  357 

Rontgen  rays  in,  356 

surgical,  351 

trypsin,  359 

vaccine,  359,  361 

with  body  fluids  of  recovered  case, 
361 
Tremoliere's  solution  in,  362 
trypsin  treatment,  359 
tryptophan  test  in,  338 
tumor  in,  330 
types  of  growth,  325 
ulcer  in  etiology  of,  322 
urinary  methylene-blue  reaction  in, 

.    341 
urine  in,  332 

vaccine  treatment,  359,  361 
Van  Slyke's  modification  of  Abderhal- 

den  test  in,  341 
varieties,  324 
vomiting  in,  329 
Wolff- Junghans  test  in,  341 
secondary  to  diverticulitis,  853 
Cancerous  ulcers  of  intestines,  759 
Canine  hunger,  490 
Cannon-ball  massage  in  constipation,  618, 

619 
Cap,  duodenal,  114 
Capillary  hemorrhoids,  783 
Caput  coli,  28,  29 

medusae,  66 
Carbohydrates,  absorption  of,  42 
in  feces,  535,  985 
in  nuts,  178 

in  urine  in  pancreatic  diseases,  988 
Carbolic  acid  injection  for  hemorrhoids, 
792 
poisoning  antidotes  for,  245 
Carbonic  acid  gas  bath  in  mucous  colic,  91 1 
for  tenesmus  in  amebic  dysentery, 

691 
inflation  of  intestines,  529 
of  stomach  with,  95 
Carcinoma.     See  Cancer. 

ventriculi  without  palpable  tumor,  grave 
anemia  in,  345 
Cardia,  cancer,  a^.     See  also  Cancer  oj 
Cardia. 
insufficiency,  487 
spasm  of,  485 
stenosis  of,  treatment,  363 


Cardiac  glands  of  stomach,  20 

orifice  of  stomach,  17 
Cardialgia,  475 
Cardioptosis,  460 
Cardiospasm,  62,  485.     See  also  Cardio- 

spasmtis. 
Cardiospasmus,  485 
diagnosis,  486 
etiology,  485 

in  simple  duodenal  ulcer,  741 
prognosis,  486 
symptoms,  485 
treatment,  59,  486 

surgical,  487 
x-ray  examination  in,  58 
Carriers  of  dysentery  bacilli,  treatment, 
699 
typhoid  fever,  708,  717 
Caruncula  major  of  pancreas,  958 

minor  of  pancreas,  958 
Cascara  sagrada  in  constipation,  621 
Casein  test  for  pepsin,  152 
Catarrh,  drunkard's,  248 
intestinal,  643.     See  also  Enteritis.  . 
of   pancreas,  1005 
acute,  1005 
chronic,  1006 
suppurative,  1007 
of  stomach,  236.     See  also  Gastritis. 
Catarrhal  appendicitis,  acute,  805 
simple  acute,  806 
ulcer  of  intestine,  758 
Catarrhus    atrophicans,    262.     See    also 
Achylia  gastrica. 
intestinalis,  643 
acutus,  643 
Caustic  alkalis,  antidotes  for,  245 
Cecostomy  in  modified  cecostomy,  692 
Cecum,  29 

arterial  supply,  31 
lymphatics,  31 
movable,  639 
nerves,  31 
Celiac  axis,  aneurysm,  cancer  of  pylorus 

and,  differentiation,  347 
Cercomonas  intestinalis,  920 
Cerebrospinal  fluid,  trichinae  in,  951 
Cestodes,  924 

Chambers'  portable  bath-tub,  713 
Chauffard's    method    of    i>ercussion    for 

hydatid  cyst  of  liver,  78 
Chest,  inspection  of,  49 
Chewing  cud,  490 
Chittenden's  caloric  table,  175 

sample  dietary,  152 
Chlorosis,  Egj^ptian,  940 

stomach  functions  in,  503 
Cholecystitis,   diagnosis  of,  by  Rontgen 
rays,  132  _ 
from  Bacillus  coli  infections,  599 
Cholecystotomy  in  chronic  pancreatitis, 

1028 
Cholelithiasis  and  acute  hemorrhagic  pan- 
creatitis, relation,  1009 
cancer  of  pancreas  and,  differentiation, 

1047 
duodenal  ulcer  and,  differentiation,  751 


io62 


IXDEX 


Cholera  nostras,  643 

Chorea,  acute  ectasy  of  stomach  in,  406 

Choroiditis  from  Bacillus  coli  infection, 

600 
Churning,  haustral,  44 
Chvostek's  symptom  in  gastric  tetany,  434 
Chyme  in  duodenum,  propulsion  of,  44 
Chymosinogen,  153 

Circulation  in  pancreatic  diseases,  999 
Circulatory  changes  in  typhoid  fever,  702 
Cirrhosis  of  liver,  gastric  ulcer  and,  differ- 
entiation, 294 
syphilitic,  gastric  cancer  and,  differ- 
entiation, 346 
of  stomach,  syphilitic,  511 
ventriculi,  249,  250 
Clamp  and  cautery  treatment  of  hemor- 
rhoids, 793 
Clapotage  in  intestinal  diseases,  523 
Cohnheim  modification  of  benzidin  blood 
test,  159 
stomach  stiff enings  of,  67 
Cold  applications  to  stomach,  224 
Coley's  toxins  in  gastric  cancer,  361 
Colic,  587 

appendicular,  811 
fecal,  614 

in  cancer  of  intestines,  774 
in  chronic  intestinal  obstruction,  treat- 
ment, 890 
intestinal,  587.     See  also  Enteralgia. 
mucous,  905 

abdominal  support  in,  910 
age  and,  906 

carbonic  acid  gas  bath  in,  911 
constipation  in,  treatment,  910 
cramps  in,  treatment,  910 
diet  in,  910,  913 
enteroclysis  in,  911 
enteroptosis  and,  908 
etiology,  906 
exercise  in,  913 
history,  905 
in  children,  909 
in  newborn,  909 
medication  in,  910 
mixed,  treatment,  912 
pathology,  907 
prognosis,  909 
researches,  908 
sex  and,  906 
symptoms,  907 
treatment,  909 
general,  913 
surgical,  913 
Colitis,  acute,  acute  enteritis  with,  648 
chronic,  652.     See  also  Enteritis,  chronic. 
in  typhoid  fever,  treatment,  717 
membranous,  905.     See  also  Colic,  mu- 
cous. 
mucous,  905.     See  also  Colic,  mucous. 
ulcerative,  758 
Collapse  in  duodenal  ulcer,  753 
in  gastric  ulcer,  treatment,  298 
in  intestinal  obstruction,  873 
Colon,  adhesions,  641 
angulations,  641 


Colon,  arterial  supply,  31 

ascending,  29 

bacillus,  infections  by,  594.     See  also 
BaciUus  coli,  infections  by. 

corded,  in  chronic  dilatation  of  duode- 
num, 636 

descending,  30 

dilatation,  592 

distal,  movements  of,  44 

inflation,  auscultatory,  527 
with  water,  531 

location  of,  with  Rontgen  ray,  529 

lymphatics,  31 

nerves,  31 

proximal,  movements  of,  44 

transverse,  30 
position  of,  19 
Colonic  massage  bags,  565 

nebulizer,  565,  566 
Colon-tube,  555 

Coma  in  cancer  of  stomach,  332 
Compress,  Priessnitz's,  224 
Compression  of  intestines,  860 

mechanism,  863 
Concretions  in  feces,  538 
Condurango  in  gastric  cancer,  358 
Condyloma,  hemorrhoids  and,  differentia- 
tion, 786 
Constipatio  alvi,  609 
Constipation,  609 

agar-agar  in,  621 

aloes  in,  622 

as  cause  of  appendicitis,  803 

atonic,  611 

auto-intoxication  in,  615 

auto-massage  in,  619 

cannon-ball  massage  in,  619 

cascara  sagrada  in,  621 

diagnosis,  616 

diet  in,  617 

electricity  in,  619 

enteroclysis  in,  620 

etiology,  609 

fecal  colic  in,  614 
treatment,  623 
fever  in,  615 
tumor  in,  614 
treatment^  623 

foods,  causing,  569 

fragmentarj^  613 

glycerin  injections  in,  621 

gymnastic  exercises  in,  619 

habitual,  609 

hemorrhoids  and,  784 

hydrotherapy  in,  620 

in  atonic  ectasy  of  stomach,  treatment, 

430 
in  cancer  of  intestines,  774 

of  stomach,  332 
in  chronic  atony  of  stomach,  treatment, 
401 

enteritis,  658 

gastritis,  treatment,  260 

intestinal  obstruction,  885 
in  gastric  cancer,  treatment,  363 
in  gastroptosis,  treatment,  467 
in  hemorrhoids,  treatment,  787 


INDEX 


1063 


Constipation  in  mucous  colic,  treatment, 
910 
in  volvulus,  866 
injections  in,  620 
intestinal  diverticula  and,  848 

sapremia  in,  613 
massage  in,  618 
medication  in,  621 
mineral  oil  treatment,  621 
obstinate,  615 
olive  oil  in,  617,  621 
orthopedics  in,  621 
physical  treatment,  618 
podophyljin  in,  622 
predisposing  causes,  611 
prognosis,  616 
prophylaxis,  616 
regulin  in,  621 
rhubarb  in,  622 
saline  laxatives  in,  623 
spastic,  612 

sweet  oil  injection  in,  620 
symptoms,  613 

nervous,  615 
tamarinds  in,  622 
termination,  614 
training  of  patient,  617 
treatment,  616 
vibratory  massage  in,  619 
Constitutional  diseases,  intestinal   ulcers 

in,  759 
Contact  ulcer  of  duodenum,  732 
Convulsions  in  chronic  ectasy  of  stomach, 

435 
Copper  poisoning,  antidotes  for,  245 
Coproliths  in  feces,  539 
Coprostasis  in  acute  ectasy  of  stomach,  408 
Corde  colique  transverse  in  enteroptosis, 

444 
Corrosive  sublimate,  antidotes  for,  245 
Corset  for  abdominal  support,  235 

Gallant,  462 

La  Grecque,  462,  463 

proper  method  of  adjusting,  462 

Van  Orden,  463 
Counterirritation,  225 
Cruveilhier's     disease,     277.     See     also 

Ulcer  of  stomach. 
Crystals  in  feces,  540 
Cud,  chewing,  490 
Curtis  spring  pad,  235 
Curvature,  greater,  of  stomach,  18 

lesser,  of  stomach,  18 
Cutaneous  burns,  intestinal  ulcers  from, 

.  754' 
Cyanosis  enterogenic,  583 

treatment,  583 
Cyclic  vomiting  in  children,  492 
Cynorexia,  470 

Cystadenoma  of  pancreas,  1036 
Cystic  epithelioma  of  pancreas,  1036 

tumors  of  pancreas,  1036 
C.vsts  of  pancreas,  1035 

classification,  1035 

contents,  1038 

diagnosis,  1043 

emaciation  in,  1039 


Cysts  of  pancreas,  etiology,  1035,  1037 
hydatid,  1036 
physical  signs,  1039 
pressure  symptoms,  1039 
proliferation,  1036 
retention,  1035 
Rontgen  rays  in,  1038 
symptoms,  1038 
treatment,  1043 
true,  103s 

Davainea  Madagascariensis,  928 
Dawbarn's  method  of  lavage,  205 
D6bove's  meat  powder,  189,  268 
Decubital  ulcers  of  intestines,  758 
Degeneration,  amyloid,  of  pancreas,  1050 
fatty,  of  pancreas,  1050 
hyaline,  of  pancreas,  105 1 
Degenerative  changes  of  pancreas,  1050 
Deglutition  sounds  of  stomach,  99 
Dehio's  method  of  determining  position 

of  stomach,  92,  135 
Dermatitis,    uncinarial,    943       See    also 

Uncinarial  dermatitis. 
Dew-itch,  943 
Diab^te  bronze,  1053 
Diabetes,  bronzed,  1053 
pancreas  and,  relation,  1051 
stomach  functions  in,  505 
Diaphragm,  eventration  of,  441 
Diaphragmatic  hernia,  439,  862 
acquired,  440 
congenital,  440 
diagnosis,  440 

differential,  441 
paradoxic    expiratory    displacement 

in,  440 
physical  signs,  862 
prognosis,  441 
Rontgen  rays  in,  440 
symptoms,  440 
treatment,  441 
Diarrhea,  624 

acute,  643 
'  cathartica,  625 
'  classification,  625 
due  to  irritation  of  bowel  contents,  625 
dyspeptica,  625 

treatment,  628 
entozoica,  626 
from  balantidium  coli,  923   • 

treatment,  924 
from  exposure  to  cold  and  wet,  627 
from  intestinal  parasites,  treatment,  628 
from  irritants  transmitted  in  blood,  626, 

628 
gastrica,  625 
treatment,  628 
in  chronic  enteritis,  658 

intestinal  obstruction,  885 
in  gastric  cancer,  treatment,  363 
in  intestinal  ulcer,  760 
in  typhoid  fever,  treatment,  715 
nervous,  626,  901 
treatment,  628 
stercoral,  treatment,  628 
stercoralis,  626 


1064 


INDEX 


Diarrhea  stercoralis,  treatment,  628 
treatment,  627 
tubular,  905 
Diastase  in  feces,  test  for,  537 
Diastatic  ferments,  pancreatic,  985 
Diazo-reaction  in  typhoid  fever,  705 
Diet,  172 

after  gastro-enterostomy,  194 

before  gastro-enterostomy,  194 

for  reduction  in  obesity,  916 

general  rules  of,  189 

in  achlorhydria  haemorrhagica  gastrica, 

274 
in  achylia  gastrica,  194,  267 
in  acute  appendicitis,  836 

enteritis,  652 

stomach  disease,  192 
in  atonic  ectasy  of  stomach,  425-427 
in  bacillary  dysentery,  699 
in  cancer  of  stomach,  193 
in  chronic  amebic  dysentery,  690 

atony  of  stomach,  400 

diseases  of  stomach,  193 

entertis,  659 

gastritis,  194,  256 

intestinal  obstruction,  889 

pancreatitis,  1028 
in  constipation,  617 
in  disease,  192 
in  duodenal  ulcer,  753 
in  ectasia,  194 
in  gastric  cancer,  355 

ulcer,  302 
in  gastroptosis,  194 
in  gastrosuccorrhea  continua  chronica, 

394 

in  health,  172       - 

in  hemorrhoids,  786 

in  hyperchlorhydria,  377,  379 

in  indolic  indicanuria,  577 

in  intestinal  cancer,  778 
diseases,  568 

in  mucous  colic,  910,  913 

in  nervous  dyspepsia,  194 

in  senile  dyspepsia,  591 

in  simple  acute  gastritis,  241,  242 

in  tjT)hoid  fever,  708 

in  ulcer  of  stomach,  193 

postoperative,  195 

scales,  185,  186 
Leube-'s  186 
Dietary,  Chittenden's  sample,  152 
Diet-lists,  von  Noorden's  183-185 
Dietl's  crisis  in  gastroptosis,  treatment, 
466 
in  nephroptosis,  446,  459 
Dieulafoy's  ulcer  of  stomach,  314 
Diffuse  appendicitis,  acute,  805 
Digestibility  of  food,  186 
Digestion,  enteral,  42 

ferments  of,  33 

intestinal,  38 

parenteral,  42 

physiology,  33 
Dilatation,  diffuse,  of  esophagus,  S4 
a;-ray  examination,  57 

of  colon,  592 


Dilatation  of  duodenum,  chronic,  634 
classification,  635 
corded  colon  in,  636 
determination,  636 
pressure  paradox  in,  636 
treatment,  636 
of  esophagus,  diffuse,  without  anatomic 
stenosis,  62 
symptoms,  63 
treatment,  63 
of  sphincters  for  hemorrhoids,  791 
of  stomach,  acute,  401.     See  also  Ectasy 
of  stomach. 
Diminished  peristole,  398.     See  also  Atony 

of  stomach. 
Diphtheritic  dysentery,  666,  695 
Dipping,  69 

Dipylidium  caninum,  928 
Disinfection  in  tj^hoid  fever,  708 
Dislocation  of  stomach,  439 
Distoma  conjunctum,  930 
felineus,  931 
hematobium,  931 
hepaticum,  931 
lanceatum,  930 
lanceolatum,  931 
sinensis,  930 
Distomiasis,  930 
hemic,  931 

treatment,  934 
intestinal,  931 
Diverticula,  Meckel's,  24,  843 

diseases  of,  839,  856.     See  also  Diver- 
ticulitis. 
inflammation  of,  857 
strangulation  by,  861 
of  esophagus,  56,  57 
stenosis  of  esophagus  and,  differentia- 
tion, 52 
of  intestines,  842 

absence  of  fat  and,.  847 

acquired,  843 

cachexia  and,  847 

congenital,  842 

connective  tissue  around  vessels  and, 

849 
constipation  and,  848 
etiology,  847 
false,  842 

flatulence  and,  848 
intestinal  wall  and,  847 
muscular  deficiency  of  gut  wall,  849 
obesity  and,  847 
occurrence,  845 
perforation  in,  852 
pressure  from  within  intestines  and, 

848 
relation   of,   to  points  of  entry   of 

vessels  through  gut  walls,  848 
secondary   pathologic    processes   in, 

849 
sex  and,  847 
sigmoid  flexure  and,  848 
size,  846 

of  vessels  and,  848 
true,  842 
of  Vater,  958 


INDEX 


Io6: 


Diverticulitis,  839 
abscess  in,  853,  854 
acute,  851 
adhesions  in,  852 
carcinoma  secondary  to,  853 
chronic,  851 
clinical  aspects,  854 
diagnosis,  856 

differential,  854 

Rontgen  ray,  855 
etiology,  847 
foreign  bodies  in,  853 
gangrenous,  851 
history,  839 
inflammatory  lesions  of  abdomen  and, 

differentiation,  856 
intestinal  obstruction  and,  differentia- 
tion, 85s 
left-sided  tumor  in,  854 
mesenteritis  in,  chronic,  853 
metastatic  suppuration  in,  853 
perforation  in,  852 

of  hernial  sac  in,  853 
peritonitis,  from,  local  chronic,  853 

perforative,  852 
sigmoiditis  and,  differentiation,  855 
symptoms,  851 
submucous  fistulae  in,  853 
treatment,  856 
vesicocolic  fistula  and,  differentiation, 

Diverticulum.     See  Diverticula. 
Dochmius  duodenalis,  940 
Douche  in  stomach  diseases,  225 

stomach,  211.     SeeaisoStomachdouche. 
Douleur  thoracique  in  volvulus  of  stomach, 

442 
Drain-trap  stomach,  37 
Dripping  sounds  of  stomach,  99 
Duct  of  Santorini,  958 
Ducts  of  pancreas,  958 

of  Wirsung,  958 
Ductus  pancreaticus  accessorius,  958 
Dujardin-Beaumetz  diet  in  obesity,  917 
Dulness,  hepatic,  77 
Duodenal  alimentation,  190 
cap, 114 

deformity  of,  119 
dilated,  129 
motility,  37 
motor  function,  36 
shape,  37 
feeding  in  gastric  ulcer,  301 
regurgitation  from  fatty  foods,  482 
ulcer,  724.     See  also  Ulcer,  duodenal. 
Duodenitis,  catarrhal,  acute  hemorrhagic 
pancreatitis  and,  loio 
with  jaundice,  treatment,  651 
Duodenoscope,  Kemp's  inflating,  105-108 
sterilization,  108 
uses  of,  108 
Duodenum,  anatomy,  22 
ascending  part,  22 
cancer  of,  772 

chronic  dilatation,  634.     See  also  Dila- 
tation, chronic,  of  duodenum. 
chyme  in,  propulsion  of,  44 


Duodenum,  constriction  of,  from  abnormal 
folds  of  anterior   mesogastrium, 
748 
contents,  examination,  976 
descending  part,  22 
direct  lavage  of,  552 
Head's  zones  for,  830 
stricture  of,  ulcer  of  duodenum    and, 

differentiation,  749 
sup>erior  horizontal  part,  22 
transverse  part,  22 
Dynamic  ileus,  871 

intestinal  obstruction  by,  differentia- 
tion, 877 
Dysentery,  666 

amebic,  abdominal  soreness  in,  683 
acute,  679 
feces  in,  679 
ipecac  in,  686 
pain  in,  679 
tenesmus  in,  679 
treatment,  685 
internal,  685 
local,  688 
adhesive  peritonitis  in,  682 
after-effects,  683 
appendicostomy  in,  692 
carriers  of,  687 
cecostomy  in,  692 

Gant's  modified,  692 
chronic,  679 
diet  in,  690 
treatment,  690 
surgical,  691 
circulatory  system  in,  680 
classic  ulcers  in,  672 
cold  water  irrigation  in,  689 
complicating  bacteria  in,  677 
complications,  681  ^ 

definition,  668 
diagnosis,  683 

differential,  682 
emetin  in,  687 
healing  process  in,  673 
in  aged,  680 
in  children,  680 
intestinal  parasites  in,  677 
intestines  in,  670 
irrigation  in,  689 
latent  infection,  678 
leukocytes  in,  680 
liver  abscess  in,  675 
treatment,  692 
location  of  lesions,  674 
microscopic  pathology,  675 
nervous  system  in,  68  2 
pains  in,  678,  680,  681 
pathology,  670 
prognosis,  683 
prophylaxis,  684 
source  of  infection,  668 
splenic  abscess  in,  677 
sprue  after,  683 
subacute,  678 
symptoms,  677 
temperature  in,  680 
tenesmus  in,  680 


io66 


INDEX 


Dysentery,  amebic,  treatment,  684 
local,  688 
medical,  604 

ulceration  in,  670 

undermined  ulcers  in,  672 
bacillary,  692 

acute,  diet  in,  699 
treatment,  698 

bacillus  dysenteriae  as  cause,  693 

bismuth  treatment,  69*/ 

chronic,  diet  in,  699 
treatment,  698 

clinical  types,  695 

complications,  696 

definition,  692 

etiology,  692 

ipecac  treatment,  696 

irrigation  in,  698 

medication  in,  696 

morbid  anatomy,  694 

prognosis,  696 

prophylaxis,  696 

serum  therapy  in,  699 

symptoms,  694 

tenesmus  in,  treatment,  698 

treatment,  696 
bacilli  carriers,  treatment,  699 
catarrhal,  acute,  695 
classification,  667 
climatic  location,  667 
diphtheritic,  666,  695 
location  of  lesions  in,  670 
predisposing  causes,  667 
pre-ulceration  stage,  670 
Dyspepsia,  akoric,  591 

chronic,  248.     See  also  Gastritis,  chronic. 
gastric  acute,   236.     See  also  Gastritis 

simple  acute. 
hyperkoric,  591 
in  pancreatic  diseases,  998 
intestinal,  570 

chronic  enteritis  and,  differentiation, 
656 

treatment,  571 
nervous,  496 

chronic  gastritis  and,  differentiation, 

497 
course,  497 
diagnosis,  497 

differential,  497 
diet  in,  194 
etiology,  496 
gastric  cancer  and,  differentiation,  497 

juice  in,  496 

ulcer  and,  differentiation,  497 
neurasthenia  gastrica  and,  differentia- 
tion, 49'/ 
symptoms,  496 
treatment,  497 
senile,  590 
diagnosis,  591 
diet  in,  591 
exercise  in,  591 
gastric  analysis  in,  590 
intestinal  functions  in,  590 
symptoms,  590 
treatment,  591 


Dyspepsia,  umbilical,  899 
Dyspeptic  asthma,  499 
Dysphagia,  485 

in  cancer  of  cardia,  333 

Ear  diseases,  stomach  functions  in,  506 
Echinococci,  928 
Ectasia,  diet  in,  194 
in  gastric  cancer,  treatment,  362 
ventriculi,  414 
Ectasy,  gastrosuccorrhea  continua  chron- 
ica and,  differentiation,  393 
of  pylorus,  stenotic,  symptoms,  420 
of  stomach,  acquired,  treatment,  431 
acute,  401 

age  in  etiology  of,  404 

anuria  in,  410 

cardiac  symptoms  with,  406 

character  of  vomitus,  410 

clinical  types,  405 

coprostasis  in,  408 

diagnosis,  411 

drainage  in,  412 

duodenal  stenosis  with  motor  dis- 
turbances and,  754 

duodenum  in,  411 

duration  of  attacks,  410 

etiology,  404 

from  obstruction  of  transverse  duo- 
denum, 403 

in  epilepsy,  406 

in  migraine,  406 

in  simple  duodenal  ulcer,  741 

in  tetany,  406 

in  typhoid  fever,  407 

lavage  in,  412 

mechanism  of  production,  402 

medication  in,  413 

microscopic  examination,  411 

morbid  anatomy,  411 

operations  in,  414 

pain  in,  410 

percussion  in,  410 

peristalsis  in,  410 

physical  signs,  410 

postural  treatment,  413 

prognosis,  411 

pseudo-angina  with,  406 

sex  in  etiology,  404 

splashing  sound  in,  410 

symptoms,  408 

tenderness  in,  410 

treatment,  412 

vomiting  in,  409 
atonic,  416 

constipation  in,  treatment,  430 

course,  419 

diagnosis,  differential,  423 

diet,  425-427 

electricity  in,  428 

etiology,  416 

fermentation  in,  treatment,  430 

gastric  analysis  in,  419 
tetany  in,  treatment,  430 

gastroplication  in,  431 

gastrosuccorrhea  in,  treatment,  430 

hydrotherapy  in,  428 


INDEX 


1067 


Ectasy  of  stomach,  atonic,  in  epilepsy,  417 
in  insane,  417 
lavage  in,  428 
local  treatment,  428 
massage  in,  429 
mechanic  support  in,   427 
Rose's  plaster  belt  in,  428 
stomach  douche  in,  429 

spray  in,  429 
surgical  treatment,  430 
symptoms,  418 
treatment,  425 
benign,  gastric  contents  in,  422 

treatment,  431 
chronic,  414 

complications,  433 

convulsions  in,  435 

diagnosis,  differential,  416 

epilepsy  in,  435 

tetany  in,  433,     See  also  Tetany  in 

ectasy  of  stomach. 
treatment,  425 
congenital,  treatment,  431 
malignant,  treatment,  433 
medication  in,  429 
obstructive,  419.     See  also  Ectasy  of 

stomach,  stenotic. 
onset,  409 
prophylaxis,  412 
types,  401 

stenotic,  89,  416,  419 
acquired,  419 
congenital,  419 

treatment,  421 
diagnosis,  422,  423 
differential,  423 
etiology,  419 
inflation,  424 
inspection,  422 
malignant,  421 

gastric  contents  in,  422 
motor  functions  in,  424 
palpation,  423 
pathology,  420 
percussion,  422 
special  type,  421 
test-breakfast  in,  424 
transillumination,  424 
treatment,  431 
vomiting  in,  treatment,  432 
a;-rays  in,  424 
Eczema,  stomach  functions  in,  506 
Edebohls'  palpation  in  chronic  app>endi- 

citis,  823 
Edema  in  cancer  of  stomach,  332 
Egyptian  chlorosis,  940 
Ehrlich's  diazo-reaction  in  typhoid  fever, 

705 
Einhorn's  bead  test  for  intestinal  motor 
functions,  543  A 
benzidin  test  paper,  159 
deglutible  electrode,  217 
disease,  317.     See  also  Erosions  of  stom- 
ach, chronic. 
duodenal  feeding,  190 

pump  for  obtaining  pancreatic  fer- 
ments, 974,  Q75 


ICinhorn's  esophagoscope,  99 
gastric  spray,  214 

stamper  test  for  gastric  ulcer,  295 
gastrodiaphane,  109 
gastrograph,  171 
meat  powder,  268 
methods  of   recognizing  gastric  ulcer, 

294,  295 
pyloric  dilator  for  pylorospasmus,  484 
radiodiaphane,  134 
stomach  powder-blower,  215 
stool  sieve,  538 

technic    of    transillumination  of  intes- 
tines, 528 
thread   impregnation    test   for   gastric 

ulcer,  294 
treatment  of  gastric  ulcer,  301 
Electricity  in  atonic  ectasy  of  stomach,  429 
in  chronic  atony  of  stomach,  401 

gastritis,  255 
in  constipation,  619 
gastroptosis,  465 
in  hyperchlorhydria,  382 
in  intestinal  diseases,  566 
in  stomach  diseases,  216 

combined  with  vibratory  massage, 

222 
high-frequency  currents,  219 
indications,  219 
intragastric  method,  216 
percutaneous  method,  216 
static  method,  219 
triphase  method,  219 
Tiirck's  gyromele,  219 
with  roller  massage  and  heat,  223, 
224 
intrarectal,  567 
Electrode,  Einhorn's  deglutible,  217 
Lock  wood's,  217 
stomach,  Bassler's,  218 
Elsberg  and  Neuhof 's  method  of  diagnosis 

by  Head's  zones,  828 
Emaciation  in  pancreatic  cyst,  1039 

diseases,  998 
Embolic  intestinal  ulcers,  755 
Embolism  of  inferior  mesenteric  artery, 
756 
of  mesenteric  arteries,  763 
clinical  symptoms,  764 
diagnosis,  756 
etiology,  763 
prognosis,  756 
Emetin  in  amebic  dysentery,  687 
Endo-appendicitis,  806 
Enema,  553,  554 

high,  with  colon- tube,  554 
in  chronic  enteritis,  661 
uses,  553 
value,  563 
Enteral  digestion,  42 
Enteralgia,  587 
diagnosis,  588 
etiology,  587 
nervous,  903 
prognosis,  588 
symptoms,  587 
treatment,  588 


io68 


INDEX 


Enteritis,  acute,  643 

acute  colitis  with,  648 

bile-pigment  and,  648 

bismuth  in,  650 

calomel  in,  649 

crypts  of  Lieberkiihn  in,  645 

diagnosis,  to  localize  lesion,  648 

diet  in,  652 

duration,  649 

enteroclysis  in,  650 

etiology,  643  _ 

fermentation  in,  treatment,  651 

fever  in,  647 

heat  in,  650 

localization,  647 

microscopic  anatomy,  645 

morbid  anatomy,  644 

opiates  in,  650 

physical  signs,  646,  647,  755 

prognosis,  649 

prophylaxis,  649 

symptoms,  645,  654 

subjective,  645 
treatment,  649 
urine  in,  647 
chronic,  652 
atrophy  in,  653 
bismuth  in,  662 
chronic  catarrhal  colitis  in,  655 
constipation  in,  658 

treatment,  661 
course,  657 
degeneration   of   muscular   coats  in, 

654 

diagnosis,  656 
differential,  658 

diarrhea  in,  658 

diet  in,  659 

enema  in,  661 

etiology,  652 

feces  in,  655 

hydrotherapy  in,  660 

hypertrophy  in,  653 

intestinal  dyspepsia  and,  differentia- 
tion, 656 

massage  in,  660 

medication  in,  661 

mineral  waters  in,  660 

morbid  anatomy,  653 

mucus  in  feces  in,  656 

prognosis,  658 

rectal  examination  in,  653,  658 

treatment,  659 
local,  662 
surgical,  663 

ulceration  in,  654 
chronica,  652  ^ 

atrophicans,  674 

cystica,  653  » 

follicularis  seu  nodularis,  645' 
membranacea,  656  • 

membranous,  905.     See  also  ColiCf  mu- 
cous. 
phlegmonous,  665 
polyposa,  653 
pseudomembranous,  905 
purulent,  665 


Enteroclysis,  double-current,  555 
without  bed-pan,  560 
in  acute  enteritis,  650 
in  constipation,  620 
in  mucous  colic,  911 
in  simple  acute  gastritis,  240,  241 
value,  563 
Enterocolitis,  chronic,  652 
Enterogenic  cyanosis,  583 

treatment,  583 
Enterokinase,  40,  970 
Enteroliths,  871 
in  feces,  539 

intestinal    obstruction   by,    differentia- 
tion, 876 
Enteroptosis,  448,  592.     See  aho  Gastrop- 
tosis. 
mucous  colic  and,  908 
Rontgen-ray  for  determining,  1 24 
Epilepsy,  acute  ectasy  of  stomach  in,  406, 
417 
in  chronic  ectasy  of  stomach,  435 
Epithelial  cells  in  gastric  contents,  167 
Epithelioma  of  pancreas,  cystic,  1036 

of  stomach,  324 
Epithelium  in  feces,  541 
Erb's  sign  in  gastric  tetany,  434 
Erepsin,  40,  42 
of  stomach,  315 
acute,  315 

bismuth  treatment,  317 
chronic,  315 

emaciation  in,  316 
etiology,  316 
gastric  analysis  in,  317 
pains  in,  316 
pathology,  316 
prognosis,  317 
symptoms,  316 
treatment,  317 
weakness  in,  316 
hemorrhagic,  315 
nitrate  of  silver  treatment,  317 
Eructation,  487 

Erythema,  stomach  functions  in,  507 
Erythrocytes  in  feces,  541 
Esculin  in  gastrodiaphany,  no 
Esophageal  bougie,  50 
diseases,  examination,  50 
orifice  of  stomach,  17 
sounds,  use  of,  55 
Esophagitis,  acute,  60 

chronic,  60 
Esophagoplasty  in  cancer  of  esophagus,  64 
Esophagoscope,  Einhorn's,  99 
Jackson's,  102 
Killian's,  Brunning's  modification,  103, 

104 
Lewisohn's,  102 
Esophagoscopy,  99 

contraindications  for,  104 
correct  position  for,  loi,  102 
for  foreign  bodies,  103,  104 
in  cancer  of  esophagus,  64 
indications  for,  104 
Jackson's  instruments  for,  102 
Roser  position  for,  loi,  102 


INDEX 


1069 


Esophagoscopy,  technic,  100 

thimble  gag  or  bite  block  for,  f^i 
Esophagus,  auscultation  of,  51 
benign  growths  of,  65 
cancer,  of,  63.     See  also  Cancer  of  esoph- 
agus. 
dilatation  of,  diffuse,  54 

without  anatomic  stenosis,  62 

symptoms,  63 
re-ray  examination,  57 
diverticulum  of,  56,  57 

stenosis  of  esophagus  and,  differentia- 
tion, 52 
examination  of,  50 
instrumental,  51 
foreign  bodies  in,  59 
palpation  of,  50 
paralysis  of,  syphilitic,  62 
perforation  of,  61 
Rontgen  rays  in  diagnosis  of  diseases  of, 

113 
spasm  of,  in  gastric  cancer,  334 
splashing  sound  in,  51 
stenosis  of,  diverticulum  of  esophagus 

and,  differentiation,  52 
stricture  of,  62 

benign, .examination  in,  54 
thiosinamin  in,  59 
treatment,  59 
malignant,  examination  in,  55 
ulcers  of,   61.     See  also  Ulcer  of  esoph- 
agus. 
jf-ray  examination,  56 
Et4t  mamelonne,  249 
Eventration  of  diaphragm,  441 
Ewald's  aspirating  tube,  139 
test-meal,  136 

treatment  of  gastric  ulcer,  301 
Ewald     and     Boas'     expression     method 
of    aspirating    gastric  contents, 
141 
test-breakfast,  137 
Ewald  and  Siever's  salol   test  of  motor 

power  of  stomach,  170 
Examination,  physical,  general  methods. 

Exercise  in  gastroptosis,  463 

in  intestinal  diseases,  566 

in  mucous  colic,  913 

in  obesity,  918 

in  senile  dyspepsia,  591 

open-air,  in  obesity,  916 
Exulceratio  simplex,  314 
Eye  diseases,  stomach  functions  in,  506 

Faber  and  Penzoldt's  test  for  absorptive 

power  of  stomach,  168 
Fairchild's  anematose,  191 
Fan-douche,  225 
Fasciola  hepatica,  930 
Fasting  stomach.     See  Stomach,  fasting. 
Fat,  188 

absence  of,  diverticula  of  intestines  and, 

847 
absorption,  42 

effect  of  extirpation  of  pancreas  on, 
980 


Fat  in  feces,  535,  539 

in  diseases  of  pancreas,  981 

Robson  and  Cammidge's  test  for, 
981 
necrosis  in  pancreatic  diseases,  1000 
of  appendix,  appearance,  1029 
of  pancreas,  1029 
etiology,  1030 
location,  1029 
pathology,  1029 
treatment,  1030 
Fats  in  feces,  980 
Fat-splitting  ferment  in  urine  in  pancreatic 

diseases,  991 
Fatty  degeneration  of  pancreas,  1050 

feces,  537 
Fecal  colic,  614 
fever,  615 
tumors,  614 
Feces,    accumulation,    chronic    intestinal 
obstruction  from,  887 
in  acute  appendicitis,  836 
intestinal  obstruction  by,  differentia- 
tion, 877 
acoholic,  536 
albumin  in,  535 
bile-pigment  in,  536 

sublimate  test  for,  549 
biliar}'  acids  in,  536 
blood  in,  533,  535 

in  intestinal  ulcer,  761 
Boas-Oppler  bacilli  in,  in  gastric  cancer, 

,342 
calculi  in,  539 
carbohydrates  in,  535,  985 
chemic  examination,  534 
color  of,  in  steatorrhea,  983 
colorless,  536 
concretions  in,  538 
coproliths  in,  539 
crystals  in,  540 
diastase  in,  test  for,  537 
diastatic  ferments  in,  Wynhausen's  test 

for,  985 
Einhorn's  sieve  for,  538 
enteroliths  in,  539 
epithelium  in,  541 
examination,  532 

after  test-diet,  results,  551 
bacteriologic,  from  test-diet,  547 
chemic,  534 

after  test-diet,  549 
for  parasitic  ova,  542 
from  test-diet,  545-551 
macroscopic,  533,  545 
after  test-diet,  545 
fat  in,  535,  539,  980 

in  diseases  of  pancreas,  981 

Robson   and    Cammidge's    test, 
982 
fatty,  537 

fermentation  test  for,  549 
ferments  in,  537 
food  remnants  in,  533 
foreign  bodies  in,  530 
gas  fermentation  in,  535 
in  acute  amebic  dysentery,  679 


1070 


INDEX 


Feces  in  chronic  enteritis,  655 
pancreatitis,  1026 
in  intestinal  cancer,  770,  775 
in  pancreatic  disease,  character,  986 

reaction,  986 
indol  in,  test  for,  550 
intestinal  parasites  in,  534 
macroscopic  findings,  533 
masses,  intestinal  obstruction  from,  871 
microorganisms  in,  542 
microscopic  examination,  539 
.     mucus  in,  533,  541 

examining  separate  particles,  535 
in  chronic  enteritis,  656 
in  intestinal  ulcer,  761 
nitrogen  in,  985 
normal  reaction,  534 
odor,  533 

pancreatic  calculi  in,  539 
ferments  in,  obtaining,  978 
Gross'  method,  978 
pea-soup,  in  typhoid,  704 
peptone  in,  535 
propeptone  in,  535 
pus  in,  533,  541 

in  intestinal  cancer,  775 
ulcer,  761 
putrefactive  products  in,  test  for,  550 
red  blood  cells  in,  541 
tissue  shreds  in,  in  intestinal  ulcer,  761 
tubercle  bacilli  in,  in  intestinal  ulcer,  761 
tumor  fragments  in,  541 
quantity  of,  41 
reaction  of,  41 
skatol  in,  tests  for,  550 
starch  in,  535 
stercobilin  in,  536 
sugar  in,  535 
test  for  mucin  in,  534 
trypsin  in,  test  for,  537 
urobilin  in,  536 
Fedeli  and  Romani's  method  for  estimat- 
ing diastatic   function    of    pan- 
creas, 986 
Feeding  after  gastro-enterostomy,  194 
before  gastro-enterostomy,  194 
duodenal,  190 
forced,  208 

method  for  sparing  stomach,  189 
postoperative,  195 
rectal,  191 
Fermentation  in  acute  gastritis,  treatment, 
^51 
in  atonic  ectasy  of  stomach,  treatment, 

430 

in  chronic  gastritis,  treatment,  259 

in  small  intestine,  41 

test  for  feces,  549 
Ferments  in  feces,  537 

of  digestion,  33 

of  intestine  organized,  40 

of  pancreatic  juice,  39 

pancreatic,    970.     See   also   Pancreatic 
ferments. 
Fever,  fecal,  615 

in  acute  enteritis,  647 

in  intestinal  ulcer,  761 


Fibro-adenoma  of  pancreas,  1049 
Fibroid  degeneration  of  vermiform  appen- 
dix, 809 
Fibroma  of  intestines,  780 
Fibromyoma  of  intestines,  780 
Fish-hook  stomach,  37,  120,  121,  455 
Fissure  of  anus  in  hemorrhoids,  796 
Fistula  in  ano,  799 
submucous,  in  diverticulitis,  853 
vesicocolic,  diverticulitis  and,  differen- 
tiations, 855 
Fitz's  classification  of  acute  pancreatitis, 

1008 
Flank  tympanites,  874 
Flatulence,  584 

diverticula  of  intestines  and,  848 
Flatus  in  proctoclysis,  564 
Fleisher's  test  for  urobilin  in  feces,  536 
Fletcherism,  174 
Flicking  percussion,  72 
Floating  kidney,  445.     See  also  Nephrop- 
tosis. 
liver,  459 
spleen,  82 
Fluke  worms,  930 
Fluorescein  in  gastrodiaphany,  1 1 1 
Fluorescent  media  for  gastrodiaphany,  no 
Fluoroscopy  for  determining    cancer   of 

stomach,  129 
Focal  necrosis  of  pancreas,  105 1 
Follicles,  solitary,  of  small  intestine,  27 
Follicular  ulcers  of  intestines,  758 
Food,  aversion  to,  472 

chemic  composition  of,  181-183 
constipating,  569 

determination  of  caloric  value,  183 
digestibility,  186 
effect  of  seasoning,  569 
fatty,  duodenal  regurgitation  from,  402 
idiosyncrasies  to,  474 
in  vomit,  156 
insalivation  of,  174 
laxative,  568 
mastication  of,  174 
potential  energy  of,  174 
proprietary,  list,  189 
regurgitation,  489 
remnants  in  feces,  533 
Foreign  bodies  as  cause  of  appendicitis,  804 
esophagoscopy  for,  103 
in  diverticulitis,  853 
in  esophagus,  59 
in  feces,  539 
in  stomach,  367 

treatment,  369 
intestinal  obstruction  by,  871 
differentiation,  877 
treatment,  881 
Fore-stomach,  437 
Fragmentary  constipation,  613 
Fremitus,  hydatid,  transthoracic,  78 
Frenum  carunculae  of  pancreas,  958 
Friedlieb's  apparatus  for  lavage,  204 

method  of  lavage,  203 
Fundus  glands  of  stomach,  20     . 

of  stomach,  17 
Funnel  method  of  lavage,  196 


INDEX 


IO71 


Galactose,  absorption  of,  42 
Gallant  corset,  462 

Gall-bladder,  acute  perforation  of,  perfora- 
tion in  simple  duodenal  ulcer  and, 
differentiation,  745 
cancer  of,  gastric  cancer  and,  differen- 
tiation, 349 
distended,    movable    kidney    and,   dif- 
ferentiation, 87 
Head's  zones  for,  831 
in  chronic  pancreatitis,  1025 
in  typhoid  fever,  702 
'  palpation  of,  76 
percussion  of,  77 
physical  examination,  75 
symptoms  in  gastroptosis,  460 
Gall-stones,  chronic  pancreatitis  and,  dif- 
ferentiation, 1027 
diagnosis  of,  by  Rontgen  rays,  132 
gastralgia  and,  differentiation,  478 
intestinal  obstruction  by,  differentiation, 

876 
ulceration  of,  into  duodenum,  duodenal 
ulcer  and,  differentiation,  751 
Galvanization,  direct,  in  gastrosuccorrhea 

continua  chronica,  396 
Gangrenous  appendicitis,  808 
pancreatitis,  1012 

accumulation  of  fluid  in  lesser  f>eri- 

toneal  cavity,  1012 
diagnosis,  1014 

differential,  1014 
etiology,  1012 
leukocytosis  in,  1014 
pathology,  1012 
symptoms,  1013,  1014 
treatment,  1015 
Gant's  examining  speculum,  520 
hinged  speculum,  520 
modified  cecostomy  in  amebic  dysen- 
tery, 692 
water  infiltration  treatment  of  hemor- 
rhoids, 793 
Gas  cysts  of  intestines,  781 
fermentation  in  feces,  535 
of  gastric  contents,  156 
Gastralgia,  475 

achylia  gastrica  and,  differentiation,  477 

as  neurosis,  476 

cancer  of  stomach  and,  differentiation, 

.477 
chronic    gastritis    and,    differentiation, 

477 
diagnosis,  differential,  477 
duration,  476 
etiology,  476 

from  cerebral  disease,  476 
from  malarial  infection,  476 
from  spinal  disease,  476 
gall-stones  and,  differentiation,  478 
gastric  ulcer  and,  differentiation,  477 
hyperchlorhydria   and,   differentiation, 

477  . 
hypersecretion  and,  differentiation,  477 
intercostal   neuralgia    and,    differentia- 
tion, 478 
intestinal  colic  and,  differentiation,  478 


Gastralgia,    myalgia  and,  differentiation, 
477 
nervous,  gastric  cancer  and,  differentia- 
tion, 349 

hyperchlorhydria  and,  differentiation. 
376 
originating  in  stomach,  476 
perigastritis  and,  differentiation,  478 
prognosis,  477 

pyloric  stenosis  and,  differentiation,  477 
reflex  causes,  476 

renal  calculi  and,  differentiation,  478 
rheumatism  and,  differentiation,  477 
sex  in  etiology,  476 
symptoms,  476 
tabes  and,  differentiation,  477 
treatment,  478 
Gastralgokenosis,  470 
Gastrectasy,  414 

Gastrectomy,  partial,  for  cancer,  353,  354 
Gastric  analysis  in  achlorhydria  hsemor- 
rhagica  gastrica,  271 
cancer,  vomitus  in,  335 
catarrh.     See  Gastritis. 
contents,  abnormal  constituents  of,  158 

amylopsin  in,  158 

aspiration  of,  139.     See  also  Aspira- 
tion of  gastric  contents. 
contraindications  to,  138 

bile  in,  1 58 

blood  in,  159.     See  also  Blood. 

Boas-Oppler  bacilli  in,  166 

epithelial  cells  in,  167 

examination,  143 
microscopic,  163 

gases  in,  156 

gastric  mucosa  fragments  in,  167 

Giinzburg's  test  for,  155 

in  chronic  gastritis,  251 

intestinal  juice  in,  158 

Megastoma  entericum  in,  164 

microscopic  examination,  165 

mold  in,  167 
treatment,  168 

mucus  in,  158 

Oidium  albicans  in,  167 

Penicillium  glaucum  in,  167 

pepsin  in,  150.     See  also  Pepsin. 

peptone  in,  150 

propeptone  in,  150 

reaction,  144 

rennet  in,  152.     See  also  Rennet. 

Sahli's  desmoid  test  of,  155 

sarcinas  in,  166 

Strep  to  thrix  Foersteri  in,  167 

Trichomonas  hominis  in,  164 

trypsin  in,  158 

tumor  particles  in,  167 

volatile  acids  in,  150 

yeast  in,  166 
crises  cf  tabes,  512 
erosions,  315 

hemorrhage.     See  Hemorrhage. 
insufficiency,  399 
juice,  33 

bacteria  in,  34 

chronic  continuous  secretion  of,  391 


1072 


INDEX 


Gastric  juice,  continuous  secretion,  386. 

See  also  Gastrosuccorrhea. 

effect  of  beef  extracts  on  flow,  35 

of  meat  juice  on  flow,  35 
excessive  flow,  386.     See  also  Gastro- 
succorrhea. 
hydrochloric  acid  in,   2>2>-     See  also 

Hydrochloric  acid. 
in  nervous  dyspepsia,  496 
in  periodic  vomiting,  492 
intermittent  secretion,  387 
periodic  continuous  flow,  387 
quantity  secreted,  35 
secretion  of,  35 

effect  of  nervous  influences  on,  35 
of  sham  feeding  on,  35 
mucosa,  atrophy  of,  250,  262.     See  also 
Achylia  gastrica. 
fragments  in  gastric  contents,  167 
neuroses,  chronic  gastritis  and,  differ- 
entiation, 253 
secretion,  microscopic  examination,  163 
tetany   in   atonic   ectasy   of   stomach, 

treatment,  430 
ulcer,  277.     See  also  Ulcer  of  slomach, 
achlorhydria  haemorrhagica  gastrica 
and,  differentiation,  272 
Gastrin,  35 
Gastritis,  acid,  248 

duodenal  ulcer  and,   differentiation, 

751 
hjrperchlorhydria  and,  differentiation, 
376 
acute,  236 
atrophic,   249,   262.     See  also  Achylia 

gastrica. 
cancer  of  stomach  and,  322 
chronic,  236,  248 
absorption  in,  252 
achlorhydria  haemorrhagica  gastrica 

and,  differentiation,  253,  273 
achylia  gastrica  and,  differentiation, 

253 
alkaline-saUne  waters  in,  257 
belching  in,  treatment,  259 
cancer  and,  differentiation,  253 
catarrhal,  248 
classification,  248 
constipation  in,  treatment,  260 
course,  252 
definition,  248 
diagnosis,  251 

differential,  252 
diet  in,  194,  256 
electricity  in,  255 
etiology,  248 

fermentation  in,  treatment,  259 
gastralgia  and,  differentiation,  477 
gastric    cancer    and,    differentiation, 

349 

contents  in,  251 

neuroses  and,  differentiation,  253 
hygiene,  254 
inspection,  251 
lavage  in,  255 
massage  in,  255 
medication  in,  258 


Gastritis,  chronic,  microscopic  examina- 
tion in,  252 
morbid  anatomy,  249 
motor  function  in,  252 
nausea  in,  treatment,  259 
nervous  dyspepsia  and,  differentia- 
tion, 497 
symptoms  in,  treatment,  260 
palpation,  251 
percussion,  251 
physical  examination,  251 
prognosis,  253 
prophylaxis,  254 
saline  waters  in,  257 
smoking  in,  257 
splashing  sound  in,  251 
stomachics  in,  259 
symptoms,  258 
treatment,  253 
local,  254 
medicinal,  258 
ulcer  and,  differentiation,  253 
urine  in,  251 

vomiting  in,  treatment,  259 
hyperpeptica,  248 
hypersthenic,  248 
phlegmonosa,  246 
phlegmonous,  246 
age  of  occurrence,  247 
diagnosis,  247 
duration,  247 
etiology,  246 
morbid  anatomy,  247 
symptoms,  247 
treatment,  248 
polyposa,  249 

simple  acute,  diagnosis,  238 
diet  in,  241,  242 
duration,  238 
enteroclysis  in,  240,  241 
etiology,  236 
beat  in,  240 

jaundice  in,  treatment,  240 
microscopic  anatomy,  237 
morbid  anatomy,  237 
nausea  in,  treatment,  239 
physical  examination  in,  238 
prophylaxis,  239 
pyrosis  in,  treatment,  239 
symptoms,  238 
treatment,  239,  241 
urine  in,  238 

vomiting  in,  treatment,  239 
toxic,  243 

anatomy,  243 
diagnosis,  244 
etiology,  243 
prognosis,  244 
symptoms,  243 
treatment,  244 
Gastrodiaphane,  Einhorn's,  109 
Kemp's  circumscribing,  log,  no 
Lockwood's,  109 
Gastrodiaphany,  109,  135 
esculin  in,  no 
fluorescent  media  for,  no 
fluorescin  in,  in 


INDEX 


1073 


Gastrodiaphany  glycerin  in,  in 

in  gastroptosis,  112,  449 

technic,  112 
Gastrodynia,  475 

Gastro-enterostomy,  feeding  before  and 
after,  194 

for  cancer,  355 
Gastrofaradization,  218 
Gastrogalvanization,  218 
Gastrograph,  Einhorn's,  171 
Gastro-intestinal  hemorrhage,  occult,  phe- 
nolphthalein  test  for,  160 

symptoms  in  appendicitis,  815 
Gastrojejunal  ulcer  following  gastric  ulcer, 

treatment,  312 
Gastroptosis,  89,  442 

abdominal  support  in,  462 

after  confinement,  447 

age  in,  447 

anatomic  considerations,  443 

belt  test  in,  461 

Beyea's  operation  for,  467 

complications  in,  treatment,  467 

constipation  in,  treatment,  467 

crescentic,  451 

definition,  442 

diagnosis,  90,  460 

diet  in,  194 

Dietl's  crisis  in,  treatment,  466 

electricity  in,  465 

elevation  of  foot  of  bed  in,  466 

exercise  in,  463 

existing,  treatment,  462 

gall-bladder  symptoms  in,  460 

gastric  analysis  in,  449 

gastrodiaphany  in,  112,  449 

Glenard's  belt- test  in,  461 
theory  of,  443 

gymnastics  in,  463 

hydrotherapy  in,  466 

increase  of  abdominal  pressure,  464 

inflation  in,  449 

inspection,  449 

Kilmer's  belt  in,  463 

large  intestine  in,  455 

lengthening  of  stomach  in,  451 

massage  in,  464 

motor  functions  in,  450 

palpation  in,  449 

percussion  in,  449 

physical  examination,  449 

prognosis,  461 

Srophylaxis,  461 
^ontgen  ray  for  determining,  124,  126, 
461 
Rose's    adhesive  plaster  belt  in,  461, 

462 
Russell's  treatment,  465 
sex  in,  447 

small  intestine  in,  450 
splashing  sounds  in,  449 
symptoms,  447 
treatment,  461 
surgical,  467 
Van    Valzah-Hayes  belt  in,  463 
with  hyperchlorhydria,  376 
Gastroscope,  Jackson's,  105 

68 


Gastroscope,  Kemp's  inflating,  105-108 
sterilization,  loS 
uses  of,  108 
Gastroscopy,  104 
Gastrospasmus,  475 
Gastrostomy  for  cancer,  355 
in  cancer  of  esophagus,  64 
in  perforation  of  esophagus,  62 
Gastrosuccorrhea,  238,  386 
alimentary,  396 
etiology,  397 
symptoms,  397 
treatment,  397 
chronic,  391 
classification,  386 
continua  chronica,  391 
alkalis  in,  395 
diagnosis,  392 

<Ufferential,  393 
diet  in,  394 

direct  galvanization,  in,  396 
ectasy  and,  differentiation,  393 
etiology,  391 
frequency,  391 
gastric   ulcer   and   differentiation, 

393 
hyperchlorhydria    with    dilatation 

and,  differentiation,  393 
hypersecretion  in,  treatment,  395 
lavage  in,  395,  396 
medication  in,  395 
pain  in,  treatment,  395,  396 
palpation  in,  392 
prognosis,  394 
prophylaxis  in,  394 
symptoms,  392 
treatment,  394 
periodica,  387 
diagnosis,  388 
etiology,  387 
gastric  contents  in,  388 
history,  387 
lavage  in,  389 
prognosis,  389 
prophylaxis,  389 
symptoms,  387 
treatment,  389 
of  pain  in,  389 
of  thirst  in,  390 
of  vomiting  in,  389 
vomitus  in,  388 
hyperchlorhydria    and,   differentiation, 

376 
in  atonic  ectasy  of  stomach,  treatment, 
430 
Gastroxynsis,  386.     See  also  Gastrosucor- 

rhea. 
Gavage,  208 

Gelatin  in  hyperchlorhydiia,  378 
in  intestinal  diseases,  569 
in  typhoid  fever,  710 
treatment  of  gastric  ulcer,  306 
Germain  See's  test-meal,  137 
Gersuny's    adhesion    symptom    in  fecal 
tumor,  615 
of  fecal  tumor,  522 
symptom,  70 


I074 


INDEX 


Gl6nard's  belt  test  in  gastroptosis,  461 
disease,  442.     See  also  Gastroptosis. 
theory  of  gastroptosis,  443 
Glucose,  absorption  of,  42 
Glycerin  in  gastrodiaphany,  iii 
injections  in  constipation,  621 
Glycosuria,  alimentary,  in  pancreatic  dis- 
eases, 988 
Glycyltryptophan  test  in  cancer  of  stom- 
ach, 338 
Gonorrheal  ulcer  of  intestines,  759 
Gout,  stomach  functions  in,  505 
Grip,  stomach  functions  in,  505 
Gross'    double-current    stomach    douche, 
212 
method  of  obtaining  pancreatic  methods 

from  feces,  978 
tube  for  obtaining  pancreatic  ferments, 

.973,  974 
Ground-itch,  943 
Gruel  flour,  soy,  179 
Gruels,  soy,  180 

Giinzburg's  test  for  free  hydrochloric  acid, 
144 
for  gastric  contents,  155 
Gurgling  sound  of  stomach,  99 
Gymnastics  in  constipation,  619 
in  gastroptosis,  463 
in  intestinal  diseases,  566 
Gyromele,  565 
Tiirck's  219,  220 

Habitual  constipation,  609 

Haggard,  190 

Hammer,  percussion,  71 

Hart's  diet  scales,  185 

Haustral  churning,  44 

Hayes'  methods  of  determining  chronic 

duodenal  dilatation,  636 
Headache  in  hyperchlorhydria,  373 

in  typhoid  fever,  treatment,  717 
Head's    zones,    Elsberg    and    Neuhof's 
method  of  diagnosis  by,  828 
in  affections  of  appendix,  633 
of  duodenum,  830 
of  gall-bladder,  831 
of iintes  tines,  833 
of  kidney,  832 
of  liver,  831 
of  stomach,  830 
of  ureter,  832 
of  uterus  and  adnexa,  833 
of  vermiform  appendix,  833 
diagnosis  of  appendicitis,  828 
in  ileocecal  tuberculosis,  833 
Health,  diet  in,  172 
Heart  lesions,  stomach  functions  in,  504 

stimulants  in  typhoid  fever,  715 
Heartburn,  489 
Heat  in  acute  enteritis,  650 
in  simple  acute  gastritis,  240 
moist,  224 
unit,  172 
Hematemesis.     See  Hemorrhage. 
Hemic  distomiasis,  931 

treatment,  934 
Hemin  crystals,  Teichmann's  test  for,  162 


Hemin  crystals,  Stozyzowski's  modifica- 
tion, 162 
Hemmeter-Moritz  test  for  motor  power, 

171 
Hemochromatosis,  1053 

of  pancreas,  1053 
Hemofusan,  1053 
Hemolysin,  pancreatic,  992 
Hemolysis  as  diagnostic  method  in  gastric 

cancer,  340 
Hemorrhage,  gastro-intestinal  occult,  phe- 
nolphthalein  test  for,  160 
in  cancer  of  pancreas,  1046 
in  duodenal  ulcer,  Kemp's  treatment, 

752 
in  gastric  cancer,  329 
treatment,  362 
ulcer,  284 

serum  treatment,  297 
treatment,  296,  306 
in  hemorrhoids,  785 
in  pancreatic  diseases,  998 
in  simple  duodenal  ulcer,  740 
in  typhoid  fever,  death  from,  702 

treatment,  715 
intestinal,  724 
of  stomach,  276 
causes,  276 
prognosis,  277 
symptoms,  277 
treatment,  277 
pancreatic,  1008 
Hemorrhagic  necrosis  of  pancreas,  1008 
pancreatitis,  acute,  1008 
age  and,  1009 

catarrhal  duodenitis  and,  loio 
cholelithiasis  and,  relation,  1009 
etiology,  1009 
lymphatics  in,  loio 
occurrence,  1009 
pathology,  loii 
penetration  of  duodenal  contents 

into  pancreatic  ducts,  loio 
traumatic  necrosis  and,  loii 
diagnosis,  1014 

differential,  1014 
epigastric  peritonitis  in,  1013 
experimental,  1008 
leukocytosis  in,  1014 
symptoms,  1013 
treatment,  1015 
Hemorrhoids,  782 
age  and,  783 
anal  fissure  in,  796 
anatomy,  782 
arterial,  783 
bowels  in,  787 

cancer  and,  differentiation,  786 
capillary,  783 

carbolic  acid  injection  for,  792 
cauterizing  with  fuming  nitric  acid,  792 
clamp  and  cautery  treatment,  793 
complications,  793 
condyloma  and,  differentiation,  786 
constipation  and,  784 

treatment,  787 
crushing  of,  793 


INDEX 


1075 


Hemorrhoids,  diagnosis,  786 
diet  in,  786 

dilatation  of  sphincters  in,  791 
etiology,  783 
external,  anatomy,  782 
symptoms,  784 
treatment,  788 
extirpation  of,  793 
Gant's  water  infiltration  method,  793 
hemorrhage  in,  785 

treatment,  790 
hygiene  of  anus  in,  787 
internal,  anatomy,  782 

symptoms,  785 
Kemp's  ice  tube  for,  788 

soft  rubber  rectal  bag  for,  789 
tube  for,  788 
ligature  of,  792,  793 
proctitis  in,  797 
prognosis,  786 
prolapse  of  rectum  in,  793 

treatment,  795 
prolapsed,  treatment,  790 
sex  and.  783 
suture  of,  793 
symptoms,  784,  785 
tenesmus  in,  785 
treatment,  radical,  791 
ulcerated,  treatment,  790 
venous.  783 

Whitehead's  operation  for,  793 
Hemosiderin.  1053 

Hepatic  flexure  of  ascending  colon,  29 
Hernia,  diaphragmatic,  439,  862.     See  also 
Diaphragmalic  hernia. 
physical  signs,  862 
from  strangulation,  internal,  860,  861 

mechanism,  863 
perforation  of  sac,  in  diverticulitis,  853 
Hexamethylenamin    in    duodenitis    with 

jaundice,  651 
High-frequency  current  in  stomach   dis- 
ease, 219 
Hirschsprung's  disease,  592 
History  of  patient,  46 
Hodenpyl's  treatment  of  gastric  cancer, 

361        , 
Hoffmann's  sign  in  gastric  tetany,  434 
Hook-worm  disease,  940.     See  also  Unci- 
nariasis. 
Hormones,  35 

Hort's  theory  of  gastric  ulcer,  279 
Hot  applications,  continuous  steam  coil 
for,  225 
in  stomach  diseases,  224 
baths,  abdominal  examination  in,  69 
Hour-glass  stomoch,  437 
acquired,  etiology,  437 
congenital,  437 
hypotonic,  439 
Rontgen   rays  for  determining,  123, 

438 

spastic,  439 

symptoms,  437 

Wolfler's  signs  in,  438 
Houston's  valves,  32 
Hunger,  canine,  470 


Hyaline  degeneration  of  pancreas,  1051 
Hydatid  cyst  of  liver,  Chauffard's  method 
of  percussion  for,  78 
of  pancreas,  1036 
disease,  924 

fremitus,  transthoracic,  78 
Hydrochlorhydria,  nutrition  in,  373 
Hydrochloric  acid,  5^ 

combined,  Topfer's  test  for,  146 
deficit,  determination,  154 
free.  Boas'  test  for,  144 
Giinzburg's  test  for,  144 
Kemp's  test  for,  147 
Mintz's  test  for,  153 
phloroglucin-vanillin  test  for,  144 
reso rein-sugar  test  for,  144 
Riegel's  test  for,  154 
tests  for,  144,  153 
Topfer's  test  for,  145,  146 
tropaolin  00  test  for,  153 
in  gastric  cancer,  336 
Hydrogen  sulphid  auto-intoxication,  583 
Hydrotheropy  in  atonic  ectasy  of  stomach, 
428 
in  chronic  enteritis,  660 
in  constipation,  620 
in  gastroptosis,  466 
in  intestinal  diseases,  566 
local,  224 
Hydrothionemia,  583 
Hymenolepis  diminuta,  928 

nana,  928 
Hypanakinesis  ventriculi,  485 
Hyperaciditas  hydrochlorica,  370 
Hyperacidity,  370.     See  also  HypercfUor- 

hydria. 
Hyperanakinesis  ventriculi,  479,  485 
Hj^erchlorhydria,  370 
absorption  in,  374 

acid  gastritis  and,  differentiation,  376 
alcohol  in,  378 
appetite  in,  373 
atony  with,  375 
Benedict's  test  for,  374 
biliary  colic  and,  differentiation,  376 
bowels  in,  373 
care  of,  383 
complications,  375 
course,  374 
diagnosis,  375 

differential,  376 
diet  in,  377, .379 
dilatation  with,  375 

duodenal  ulcer  and,  differentiation,  750 
electricity  in,  382 
etiology,  371 
frequency,  371 

gastralgia  and,  differentiation,  477 
gastric  contents  in,  373 
ulcer  and,  281,  283,  286 
differentiation,  376 
gastrosuccorrhea    and,    differentiation, 

376 
gelatin  in,  378 
headache  in, 373 

in  duodenal  ulcer,  treatment,  753 
magnesia  in,  380 


1076 


INDEX 


Hyperchlorhydria,  medication  in,  380 

microscopic  pus  in,  376 

motor  function  in,  374 

movable  kidney  complicating,  376 
•    nervous  gastralgia  and,  differentiation, 
376 

nervous  symptoms  in,  373 

occult  blood  in,  376 

olive  oil  in,  378 

pain  in,  375 

palpation  in,  373 

pathology,  375 

percussion  in,  373 

physical  examination  in,  373 

prognosis,  375 

removal  of  causes,  376 

symptoms,  372 

thirst  in,  373 

treatment,  376 

urine  in,  373 

with  atonic  dilatation,  gastrosuccorrhea 
continua  chronica  and,  differen- 
tiation, 393 

with  gastroptosis,  376 
H3^eresthesia  of  intestines,  903 

of  stomach,  474 
Hyperinosis  in  acute  appendicitis,  818 
Hyperkinesis,  479 
Hyperkoric  dyspepsia,  591 
Hypermotility  of  stomach,  479 
Hyperorexia,  470 
Hyperpepsinia,  151 

Hyperperistalsis,  Rontgen  ray  for  deter- 
mining, 126 
Hypersecretion,  386.     See  also  Gastrosuc- 
corrhea. 

gastralgia  and,  differentiation,  477 

in  gastrosuccorrhea  continua  chronica, 
treatment,  395 

intermittent,  387 
Hypertrophy  of  mucosa  in  chronic  enter- 
itis, 653 
Hypochlorhydria,  383 

diagnosis,  386 

diet  in,  385 

etiology,  383 

medication  in,  386 

treatment,  386 
Hypodermoclysis,  192,  565 
Hj^pogastric  neuralgia,  904 
Hypoleukocytosis  in  typhoid  fever,  705 
Hypopepsinia,  151 
Hypotonic  hour-glass  stomach,  439 

Idiopathic  nervous  vomiting,  494 
Idiosyncrasies  to  food,  474 
Ileac  phlegmon,  801 
Ileaca-ileocolic  intussusception,  868 
Ileocecal  intussusception,  867 

tuberculosis,  Head's  zones  in,  833 
valve,  functions,  640 
incompetence,  640 
etiology,  640 
palpation  method  of  determining, 

636 
symptoms,  641 
treatment,  641 


Ileocolic  intussusception,  867 

Ileum,  anatomy,  23 

Ileus,  859.     See  also  Intestinal  obstruction. 

dynamic,  871 
Incisura  pancreatis,  956 
Incontinence  of  pylorus,  481 
Indicanuria,  causes,  41 
indolic,  574 
etiology,  574 
medication  in,  577 
treatment,  577 
in  pancreatic  disease,  987 
test  for,  576 
Indol  in  feces,  test  for,  550 
Indolic  indicanuria,    574.     See   also   In- 
dicanuria, indolic. 
diet  in,  577 
intestinal  putrefaction  with  saccharo- 
butyric  type,  578 
Infantilism,  pancreatic,  984,  1050 
Infarction  of  intestines,  763 
Infectious  diseases,  acute,  intestinal  ulcers 

in,  759 
Inflation  of  colon,  auscultatory,  527 
with  water,  531 
of  intestines,  uses,  531 
with  air,  529 

with  carbonic  acid  gas,  529 
of  stomach,  135 
with  air,  96 

with  carbonic  acid  gas,  95 
with  water,  96 
Infusion,  rectal,  565 
Infusoria,  920 

Ingesta,  examination  of,  143 
Insalivation  of  food,  174 
Insanity,  atonic  ectasy  of  stomach  in,  417 
Insomnia  in  typhoid  fever,  treatment,  717 
Inspection,  general,  49 
of  abdomen,  66 
of  chest,  49 
of  intestines,  517 
of  kidney,  84 
of  liver,  76 
of  neck,  50 
of  oral  cavity,  49 
of  pharynx,  50 
of  rectum,  517 
of  spleen,  80 
of  stomach,  135 
of  tongue,  49 
of  tonsils,  50 
of  uvula,  50 
Insufficiency,  gastric,  399 
motor,  399 
of  cardia,  487 
of  stomach,  481 
Interacinar  islands  of  pancreas,  966.     See 

also  Islands  of  Langerhans. 
Internal  secretion  of  pancreas,  968 
Interrogation  of  patient,  46 
Intestinal  acetonuria,  580 
classification,  580 
acidosis,  580 

classification,  580 
amebiosis,    668.     See    also    Dysentery, 
amebic. 


INDEX 


1077 


Intestinal  catarrh,  643.    See  also  Enteritis. 
colic,  587 

gastralgia  and,  differentiation,  478 
digestion,  38 
distomiasis,  931 
dyspepsia,  570 

treatment,  571 
hemorrhage,  724 
intoxications,    relation    to    vagotonia, 

894. 
irrigation  in  achylia  gastrica,  269 
juice,  40 

in  gastric  contents,  158 
myiasis,  760 
neurasthenia,  905 
obstruction,  acute,  859 

acute  peritonitis  and,  differentia- 
tion, 878     . 
auscultation  in,  874 
by  Ascaris  lumbricoides,  differen- 
tiation, 877 
by  compression,  863 
by  dynamic  ileus,  differentiation, 

877 
by  enteroliths,  871 

differentiation,  876 
by  fecal  accumulation,  differentia- 
tion, 877 
by  fecal  masses,  871 
by  foreign  bodies,  871 

differentiation,  877 
by  gall-stones,  differentiation,  876 
by  intussusception,  867.     See  also 
Intussusception. 
differentiation,  876 
by  volvulus,  865 

differentiation,  875 
collapse  in,  873 
course,  878 
diagnosis,  873 
differential,  878 

between  forms  of,  875 
between  obstruction  of  small 
and  large  intestine,  875 
etiology,  860 

from  chronic  obstruction,  872 
from  dynamic  ileus,  871 
genentl  consideration,  859 
inspection  in,  873 
ladder  pattern,  874 
lavage  in,  882 
meteorism  in,  873 
palpation  in,  874 
paralytic,  871 
pathology,  872^ 
percussion  in,  874 
prognosis,  879 
symptoms,  872 
treatment,  879 
medical,  879 
surgical,  881 
vomiting  in,  873 
by  adhesions,  861 
by  bands,  861 
by  compression,  861 
by  foreign  bodies,  treatment,  88i 
by  internal  hernia,  860,  861 


Intestinal    obstruction  by   strangulation 
from  internal  hemiae,  861 
through  slits  and  apertures,  861 
chronic,  883 

acute  obstruction  engrafted  on,  872 
anatomy,  884 

barrel-shaped  abdomen  in,  884 
bowels  in,  889 
colic  in,  treatment,  890 
complications,  888  , 
constipation  in,  885 
course,  889 
diagnosis,  888 
diarrhea  in,  885 
diet  in,  889 
etiology,  883 

from  fecal  accumulation,  887 
from  rectal  stricture,  888 
inspection  in,  886 
location,  884,  885 
pain  in,  885 

peristaltic  unrest  in,  treatment,  890 
prognosis,  889 
Rontgen  rays  in,  886 
surgical  treatment,  891 
symptoms,  885 
treatment,  889 
tympanites  in,  886 
diverticulitis  and,  differentiation,  855 
from  strangulation  of  Meckel's  diver- 
ticulum, 861 
in  cancer  of  pancreas,  1046 
pain,  587.     See  also  Enteralgia. 
parasites,  920 

as  cause  of  appendicitis,  803 
in  amebic  dysentery,  677 
in  feces,  534 
paresis,  871 
putrefaction,  chronic,  573 

combined  indolic  and  saccharobutyric 
type,  578 
sand,  593 
sapremia,  613 

splash,  stomach  splash  and,  differentia- 
tion, 98 
stasis,  chronic,  630.     See  also  Stasis, 

chronic  intestinal. 
trichinae,  951 
tuberculosis,  757 
Intestines,  absorption  from,  41 
adenoma,  779 
anatomy,  22 
angioma  of,  780 

anomalies  in  position  and  form,  592 
bacteria  of,  40 

blood-vessels,  diseases  of,  763 
compression,  860 

mechanisrti,  863 
digestion  in,  38 
diseases  of,  515 

auscultation  in,  527 

auscultatory  percussion  in,  526 

clapotage  in,  523 

diet  in,  568 

dectricity  in,  566 

exercise  in,  566 

gelatin  in,  569 


loyS 


INDEX 


Intestines,  diseases  of,  gymnastics  in,  566 

massage  in,  566 

mechanical  support  in,  566 

inspection  in,  516 

palpation  in,  521 

percussion,  525 

protrusion  of  abdomen  in,  516 

special  interrogation  of  patient  in,  515 

splashing  sound  in,  523 

succussionjn,  523 

vaginal  examination  in,  524 
diverticula  of,  842.     See     also     Diver- 
ticula of  intestines. 
ferments  of,  organized,  40 
fibroma  of,  780 
fibromyoma  of,  780 
functions,  in  senile  dyspepsia,  590 

motor,  43 

test-diet  for,  544 

testing,  543 
gas  in,  584.     See  also  Tympanites. 

cyst  of,  781 
Head's  zones  in  affections  of,  833 
hj^peresthesia  of,  903 
in  amebic  dysentery,  670 
in  typhoid  fever,  701 
infarction,  763 
inflation,  uses,  531 

with  air,  529 

with  carbonic  acid  gas,  529 
irrigation,  552.     See  also  Irrigation  of 

intestines. 
large,  absorption  in,  43 

anatomy  of,  28 

appendices  epiploicae,  29 

histology  of,  32 

motor  functions,  44 

pendulum  movements,  44 
lavage  for  diagnosis,  532 
lip>oma  of,  780 
lymphosarcoma  of,  778 

treatment,  779 
motor  function,  43 

neuroses  of,  900 
myoma  of,  780 
neoplasms,    767.     See    also   Cancer  of 

intestines. 
nervous  diseases,  900 
neuroses  of,  secretory,  905 

sensory,  903 
obstruction  of  859.     See  also  Intestinal 

obstruction. 
obturation  of,  870 
oscillating  movements,  43 
paralysis,  901 
palpation,  521 
papilloma  of,  780 
peristalsis  in,  43 

nervous  control,  45 
physical  examination,  515 
Rontgen  rays  in  examination  of,  528 
rotary  movements,  43 
sarcoma  of,  778 
small,  arterial  supply,  24 

bacteria  in,  34 

coats  of,  24 

fermentation  in,  41 


Intestines,  small,  lymphatics  of,  24 

microscopic  anatomy,  26 

motor  function,  43 

mucous  coat,  25 

muscular  coat,  24 

nerves  of,  24 

serous  coat,  24 

solitary  follicles,  27 

structure  of,  24 

submucous  coat,  25 

veins  of,  24 

villi  of,  26 

volvulus  of,  865 
strangulation.     See  Strangulation. 
transillumination,  528 
tumors  of,  767.     See  also  Cancer  of  in- 
testines. 
ulcers  of,  724 

volvulus,  865.     See  also  Volvulus. 
Intra-abdominal   pressure,    maintenance, 

445 
tumors  from  colon  bacillus  infections, 
600 
Intragastric    method    of    applying    elec- 
tricity in  stomach  diseases,  216 
Intrarectal  electricity,  567 
Intussusception,  867 
age  and,  869 
causes,  869 
diagnosis,  870 

differential,  876 
duration,  870 
frequency,  868 
ileaca-ileocolic,  868 
ileocecal,  867 
intestinal  obstruction  from,  treatment, 

881 
mechanism,  868 
of  appendix,  870 
pain  in,  869 
situation,  869 
symptoms,  869 
tumor  in,  869 
Invagination,  867.     See  also  Intussuscep- 
tion. 
Invertin,  40 

lodin  f)oisoning,  antidotes  for,  245 
lodipin  test  for  motor  power,  171 
Iodoform  poisoning,  antidotes  for,  245 
Ipecac  in  acute  amebic  dysentery,  686 

in  treatment  of  bacillary  dysentery,  696 
Iron  test  for  occult  blood,  161 
Irrigation  in  bacillary  dysenter}',  698 
of  intestines  by  patient,  562 
double-current,  555 
position  of  patient,  558 
precautions  before  inserting  tube,  557 
rotation  method,  559 
solutions  employed  in,  561 
uses,  553 
value,  563 
with  single  tube,  554 
Irrigator,  rectal,  Kemp's  flexible  recurrent, 
556 
Kemp's  glass,  556 
Ischio-rectal  abscess,  798 
Ischochymia,  414 


INDEX 


1079 


Island  of  Langerhans  blood-vessels,  967 
cells,  967 
function,  968 

intralobular  framework,  968 
position,  966 

Jackson's  esophagoscope,  102 
gastroscope,  105 

instruments  for  esophagoscopy,  102 
membrane,  637 

Rontgen  rays  in,  638 
symptoms,  638 
treatment,  639 
Jacoby-Solms  test  for  pepsin,  151 
Jaundice,  duodenitis  with,  treatment,  651 
in  chronic  appendicitis,  1024 

gastritis,  treatment,  259 
in  pancreatic  calculi,  1033 

diseases,  997 
in  simple  acute  gastritis,  treatment,  240 
duodenal  ulcer,  741 
Jejunal  ulcer,  313.     See  also  Ulcer,  jejunal. 
gastric  ulcer  after,  treatment,  312 
prognosis,  314 
Jejunum,  anatomy,  23 
Juvenile  vomiting,  494 

Katayama  disease,  933 
Kelly's  proctoscope,  518 
rectal  speculum,  short,  517 

standard,  517 
sigmoid  speculum,  518 
Kelsey's  rectal  speculum,  519 
Kemp's    circumscribing    gastrodiaphane, 
109,  110 
diet  in  obesity,  917 

table  in  gastric  ulcer,  305 
esophageal  bougie,  51 
flexible  recurrent  rectal  irrigator,  556 
glass  rectal  irrigator,  556 
ice  tube  for  hemorrhoids,  788 
inflating  gastroscope  and  duodenoscope, 

105-108 
method  of  aspirating  gastric  contents,  142 
prostatic  cooler,  788 
rectal  irrigator,  557 
soft  rubber  rectal  bag  for  hemorrhoids, 

789    ^ 
stomach-whistle,  97 
test  for  free  hydrochloric  acid,  147 
test-supper  for  motor  power,  169 
treatment  of  amebic  dysentery,  690 
of  gastric  ulcer,  298 
of    hemorrhage    in    acute    duodenal 

ulcer,  752 
of  typhoid  fever,  710 
tube  for  hemorrhoids,  788 
vacuum  bottle  method  of  proctoclysis, 

564 
Kerkring,  valvulse  conniventes  of,  25 
Kidney,  acute  unilateral  septic  infarcts 

from,  599 
Bacillus  coli  infections  of,  594,  596 

in  chronic  interstitial  nephritis, 

599 
in  pyelitis,  598 
in  typhoid  fever,  598 


Kidney  diseases,  stomach  functions  in,  504 
Head's  zones  for,  832 
in  typhoid  fever,  702 
inspection,  84 
movable,  85 

distended   gall-bladder  and, 

differentiation,  87 
with  hyperchlorhydria,  376 
palpation,  84 
percussion  of,  87 
physical  examination,  84 
surface  relations,  83 
topography,  83 
Killian's  esophagoscope,  Brunning's  modi- 
fication, 103 
Kilmer's  belt,  231-233,  234 

in  gastroptosis,  463 
Kissing  ulcer  of  duodenum,  732 
Klemperer's  oil  test  for  motor  power,  171 

test-meal,  137 
Kliinge's  aloin  test  for  occult  blood,  161 
Knapp's  director  for  lavage,  207,  209 
method  of  examination  of  stomach,  90 
of  inspecting  liver,  75 

Laceration  of  pancreas  due  to  direct 

violence,  looi 
Lactase  ferment,  970 
Lactic  acid.  Boas'  test  for,  149 
in  gastric  cancer,  337 
quantitative  estimation  of,  150 
Uffelmann's  test  for,  148 
modified,  148 
Lactose,  40 

Ladder  pattern  of  acute  intestinal  obstruc- 
tion, 874 
La  Grecque  corset,  462,  463 
Landau's  disease,  447 
Lane's  abdominal  supporter,  235 

definition   of  chronic   intestinal   stasis, 

630 
kinks,  609,  631 
Langerhans,    islands    of,   966.     See  also 

Islands  of  Langerhans. 
Lanz's  point  in  appendicitis,  812 
Lavage,  196 

by  single  operator,  200,201 
by  two  nurses,  202,  203 
contraindications,  211 
dangers  of,  196 
Dawbarn's  method,  205 
Friedlieb's  apparatus,  204 

method,  203 
funnel  method,  196 
in  achlorhydria  hsemorrhagica  gastrica, 

275 
in  acute  ectasy  of  stomach,  412 

intestinal  obstruction,  882 
in  appendicitis,  836 
in  atonic  ectasy  of  stomach,  428 
in  chronic  gastritis,  255 
in  gastric  ulcer,  297 
in  gastrosuccorrhea  continua  periodica, 

309 
in  office  practice,  197 
in  toxic  gastritis,  244 
indications  for,  208 


io8o 


INDEX 


Lavage,  Knapp's  director  for,  207,  209 

Leube-Rosenthal  method,  205 

mouth-gag  in,  206 

of  duodenum,  direct,  552 

of  intestines  for  diagnosis,  532 

position  of  operator,  198,  199 
of  patient,  198 

stomach-tube  for,  selection,  197 

technic,  198  208 

testing  tube  for,  197 

through  nostril,  207,  210 

with  glass  Y  or  T,  205 

with  patient  lying  on  back,  206 
Laxative  foods,  568 
Lead  poisoning,  antidotes  for,  245 
Lee's  cholera  table,  555 
Legumes,  cooking  of,  187 
Lenhartz's    treatment    of    gastric    ulcer, 

301 
Leube's  diet  scale,  186 
meat  pancreas,  191 
sound  method  for  determining  posi- 
tion of  stomach,  97 
test-meal,  for  motor  power,  169 
Leube-Rosenthal  meat  solution,  189 

method  of  lavage,  205 
Leube-Ziemssen  rest-cure  in  gastric  ulcer, 

300 
Leukocytosis  in  acute  appendicitis,  818 

in  gangrenous  pancreatitis,  1014 

in  gastric  cancer,  330 

in  hemorrhagic  pancreatitis,  1014 
Leukopenia  in  typhoid  fever,  705 
LcNTilose,  absorption  of,  42 
Lewisohn's  esophagoscope,  102 
Lieberkiihn's  crypts,  26 

in  acute  enteritis,  645 
Ligature  of  hemorrhoids,  792 
Lipase,  34 

Lipoma  of  intestines,  780 
Lipuria  in  pancreatic  diseases,  991 
liver  abscess  in  amebic  dsreentery,  675 

delimitation  of,  74 

diseases,  stomach  fimctions  in,  504 

dulness,  77 

floating,  459 

fluke,  930 

functions,  testing,  549 

Head's  zones  for,  831 

hydatid  cyst  of,  Chauffard's  method  of 
percussion  for,  78 

in  chronic  pancreatitis,  1025 

in  pancreatic  diseases,  999 

in  typhoid  fever,  702 

inspection,  75 

movable,  459 

palpation,  76 

percussion,  77 
auscultatory,  77 

physical  examination,  75 

spilling,  76 

syphilitic  cirrhosis  of,  gastric  cancer  and, 
differentiation,  346 
Lock  wood's  electrode,  217 

gastrodiaphane,  109 
Loewis  test  for  pancreatic  disease,  1047 
Lymphadenoma  of  pancreas,  1049 


Lymphatics  of  cecum,  31 
of  colon,  31 
of  rectum,  32 
of  small  intestines,  24 
of  stomach,  21 
Lymph  glands,   enlarged,   gastric   cancer 

and,  differentiation,  349 
Lymphosarcoma  of  intestines,  778 
treatment,  779 

MAGGOT-worm,  938 

Magnesia  in  hyperchlorhydria,  380 

Malacia,  472 

Malaria,  gastralgia  from,  476 

stomach  fimctions  in,  505 
Maltose,  40 
Massage,  221 

bags,  colonic,  565 

cannon-ball  in  constipation,  619 

in  atonic  ectasy  of  stomach,  429 

in  chronic  enteritis,  660 
gastritis,  255 

in  constipation,  618 

in  gcistroptosis,  464 

in  intestinal  diseases,  566 

in  nephroptosis,  466 

roller,  223,  224 

tapotement  in,  221 

vibratory,  221 

combined  with  electricity,  222 
in  chronic  atony  of  stomach,  400 
in  constipation,  619 
Mastication,  174 
Mathieu-R6mond  test  for  motor  power  of 

stomach,  170 
Mayo's  partial  gastrectomy  for  gastric 

cancer,  353 
Mazamorra,  943 

McBumey's  point  in  appendicitis,  812 
Meat  juice,  effect  on  flow  of  gastric  juice, 

35 
pancreas,  Leube's,  191 
IX)wder,  Debove's,  189,  268 

Einhom's,  268 
solution,  Leube-Rosenthal,  189 
Mechanical  support,  225 
Meckel's  diverticulum,  24,  843 

diseases    of,    839.     See    also    Diver- 
ticulitis. 
Megalogastria,  415,  437 
Megastoma  entericum  in  gastric  contents, 

164 
Meissner's  plexus,  24 
Meltzer's  method  of  palpation  in  appendi- 
citis, 814 
Membrane,  Jackson's,  637 
Membranes,  pericolic,  639 
Membranous  colitis,  905 

enteritis,  905.     See  also  Colic,  rmicous. 
Mercury  poisoning,  antidotes  for,  245 
Merycism,  490 

Mesenteric  artery,  embolism  of,  763.     See 
also     Embolism     oj     mesenteric 
arteries. 
inferior,  embolism,  756 

thrombosis,  756 
superior,  occlusion  of,  764 


INDEX 


1081 


Mesenteric  glands  in  typhoid  fever,  702 
veins,  embolism  of,  763 

thrombosis  of,  763.     See  also  Throm- 
bosis of  mcsenlcric  veins. 
Mesenteritis,  chronic,  in  diverticulitis,  853 
Mesentery,  growths  of,  gastric  cancer  and, 

differentiation,  350 
Mesogastrium,    anterior,    constriction    of 
duodenum  from  abnormal  folds 
of,  748 
Mesorectum,  31 

Meteorism,  584.     See  also  Tympanites. 
in  acute  intestinal  obstruction,  873 
in  volvulus,  866 
Methylene-blue  in  gastric  cancer,  359 

reaction  of  urine  in  gastric  cancer,  341 
Mett's  test  for  pepsin,  152 
Microgastria,  437 
Microorganisms  in  feces,  542 
Migrane  acute  ectasy  of  stomach  in,  406 
Milk,  digestibility  of,  187 

in  typhoid  fever,  709,  712 
Milk-sugar,  absorption  of,  42 
Mineral  oil,  absorption  of,  43 
Miner's  anemia,  940 

Mintz's  test  for  free  hydrochloric  acid,  153 
Miserere,  859 

Moerner  and  Boas'  test  for  free  hydro- 
chloric acid,  153 
Mold  in  gastric  contents,  167 

treatment,  168 
Morgagni,  columns  of,  32 
Moritz-Hemmeter  test  for  motor  power, 

171 
Morris'  point  in  appendicitis,  812 
Motility  of  duodenal  cap,  37 

of  stomach,  37 
Motor  function  of  duodenal  cap,  36 
of  intestine,  43 
of  large  intestines,  44 
of  small  intestine,  43 
of  stomach,  36.     See   also   Stomach, 
functions  of,  motor 
insuflSciency,  399 
of  first  degree,  399 
of  second  degree,  414 
relative,  416 
neuroses  of  intestines,  900 
Mouth,  bacteria  in,  34 

pemphigus,  stomach  functions  in,  507 
Mouth-gag  in  lavage,  206 
Movable  cecum,  639 
kidney,  445.     See  also  Nephroptosis. 
liver,  459 
Mucin,  test  for,  in  feces,  534 
Mucinase,  39 

Mucous  coat  of  small  intestine,  25 
of  stomach,  20 
colic,  905.     See  also  Colic,  mucous. 
colitis,  905.     See  also  Colic,  mucous. 
glands  of  stomach,  20 
Mucus  in  feces,  533,  541 

examining  separate  particles,  535 
in  chronic  enteritis,  656 
in  intestinal  ulcer,  761 
in  gastric  contents,  158 
in  vomit,  157 


Mucus,  microscopic  examination,  163 

MuflSns,  soy,  180 

Miiller's  serum  plate  method  of  examina- 
tion for  trypsin,  979 

Mumps  complicating  pancreatitis,  1004 

Murphy's  drop-method  of  proctoclysis,  563 

Muscular  coat  of  small  intestine,  24 
of  stomach,  19 

Muscle  trichinae,  951 

Musser's  method  of  inflation  of  colon,  527 

Myalgia,  appendicitis  and,  diflFerentiation, 
827 
gastralgia  and,  differentiation,  477 

Myasthenia  ventriculi,  399 

Myiasis,  intestinal,  760 

Myoma  of  intestines,  780 

Nauheim  bath  in  typhoid  fever,  713 
Nausea  due  to  abnormal  sensations,  474 
in  chronic  gastritis,  treatment,  259 

pancreatitis,  1023 
in  pancreatic  diseases,  996 
in  simple  acute  gastritis,  treatment,  239 
Nebulizer,  colonic,  565,  566 
Neck,  inspection  of,  50 
Necrosis,  fat,  in  pancreatic  diseases,  1900 
of  pancreas,  focal,  1051 

hemorrhagic,  1008 
traumatic,  acute  hemorrhagic  pancrea- 
titis and,  ion 
Needle  douche,  intestinal,  565 
Nematodes,  935 
Neoplasms.     See  Tumors. 
Nephritis,    chronic    interstitial,    Bacillus 
coli  infections  of  kidneys  in,  599 
Nephroptosis,  445,  455 
degrees  of,  456,  457 
Dietl's  crisis  in,  446,  459 
etiology,  446 
massage  in,  466 
Nerves  of  cecum,  31 
of  colon,  31 
of  rectum,  32 
of  small  intestines,  24 
of  stomach,  22 
Nervous  control  of  peristalsis,  45 
diarrhea,  626,  901 
treatment,  628 
diseases  of  intestines,  900 
dyspepsia,    496.     See    also    Dyspepsia, 

nervous. 
enteralgia,  903 
influences,  effect  on  secretion  of  gastric 

juice,  35 
symptoms  in  typhoid  fever,  703 
in  typhoid  fever,  treatment,  717 
Neuhof  and  Elsberg's  method  of  diagnosis 

by  Head's  zones,  828 
Neuralgia,  hypogastric,  904 
intercostal,    gastralgia  and,  differentia- 
tion, 478 
mesenterica,  903 
of  stomach,  475 
Neurasthenia  gastrica,  496.     See  also  £>y5- 
pepsia,  nervous. 
nervous   dyspepsia  and,  differentia- 
tion, 497 


io82 


INDEX 


Neurasthemia,  intestinal,  905 
Neuritis  in  typhoid  fever,  705 

multiple,  in  gastric  cancer,  332 
Neuroses,  motor,  of  intestines,  903 
of  intestines,  sensor>',  903,  905 
of  stomach,  469,  495 
classification,  469 
etiology,  469 
motor,  479 
peculiarities,  469 
sensory,  470,  474 
Nitric  acid,  fuming,  cauterizing  with,  in 

hemorrhoids,  792 
Nitrogen,  excessive  secretion  of,  175 

in  feces,  985 
Non-suppurative  appendicitis,  acute,  805 
Nose  diseases,  stomach  functions  in,  506 
Nuclease,  970 

pancreatic,  40 
Nutrition,  in  intestinal  ulcer,  761 

parenteral,  192 
Nuts,  carbohydrates  in,  178 

Obesity,  915 
baths  in,  918 
diet  for  reduction  in,  916 
diverticula  of  intestines  and,  847 
exercises  in,  918 
open-air  exercise  in,  916 
prevention,  915 
sex  and,  915 
symptoms,  915 

treatment,  precautions  in,  917 
Obliterative  appendicitis,  806 
Obstipatio  alvi,  609 
Obturation  of  intestines,  870 
Obturator,  rectal,  904 
Occlusion  of  superior  mesenteric  artery, 

764 
Occult    blood    in    achlorhydria    haemor- 
rhagica  gastrica,  272 
iron  test  for,  161 
Klunge's  aloin  test  for,  161 
test  for,  160 
hemorrhage  in  gastric  ulcer,  284 
Odor  of  feces,  533 

0[dium  albicans  in  gastric  contents,  167  , 
Olive  oil,  188 

hypodermoclysis,  192 
in  constipation,  617,  621 
in  hyperchlorhydria,  378 
Omentum,  greater,  19 
lesser,  19 
tuberosity  of,  957 
Opiates  in  acute  enteritis,  650  ^ 
Opisthorchis  felineus,  930 
Oral  cavity,  inspection,  49 
Orthopedic  methods  in  constipation,  621 

treatment  of  stomach  diseases,  225 
Osseous  system  in  typhoid  fever,  702,  705 
Oxyuris  vermicularis,  938 
diagnosis,  939 
symptoms,  939 
treatment,  939 

Pain   from   adhesions   in   gastric   ulcer, 
treatment,    309 


Pain  in  acute  amebic  dysentery,  679 

ectasy  of  stomach,  410 
in  amebic  dysentery,  678,  680,  681 
in  cancer  of  intestines,  774 

of  pancreas,  1045 

of  stomach,  328 
in  chronic  gastric  erosions,  316 

intestinal  obstruction,  885 

pancreatitis,  1023 
in  gastric  cancer,  treatment,  362 

ulcer,  284,  285 

treatment,  307 
in  gastrosuccorrhea  continua  chronica, 
treatment,  395,  396 
periodica,  treatment,  389 
in  hyperchlorhydria,  375 
in  intestinal  ulcer,  761 
in  intussusception,  869 
in  pancreatic  calculus,  1033 

diseases,  994 
in  simple  duodenal  ulcer,  736 
in  volvulus,  866 

intestinal,  587.     See  also  Enteralgia. 
Palpation,  Meltzer's  method  in  appendi- 
citis, 814 
of  abdomen,  67 
of  esophagus,  50 
of  gall-bladder,  76 
of  intestines,  521 
of  kidney,  84 
of  liver,  76 
of  recti  muscles,  69 
of  rectum,  524 

by  sounds,  525 
of  spleen,  80 
of  stomach,  9,  135 
of  vermiform  appendix,  811 
Rovsing-Chase  method,  in  appendicitis, 
814 
Pancreas,  aberrant,  959 
accessorium,  959 
acini,  965 

adenocystoma  papilHferum  of,  1036 
adenoma,  1049 

amyloid  degeneration  of,  1050 
annular,  959 
anomalies,  955,  959,  960 
arteries,  957 
autodigestion,  971 
blood-supply,  957 
body,  957 

bullet  wounds  of,  1002 
cancer  of,  1044.     See    also    Cancer    of 

pancreas. 
caruncula  major  of,  958 

minor  of,  958 
catarrh,  1005 

acute,  1005 

chronic,  1006 

suppurative,  1007 
changes  in   cells  of  acini  with  active 

secretion,  966 
connective-tissue  framework,  964 
cystadenoma  of,  1036 
cystic  disease,  1036 

epithelioma  of,  1036 

tumors  of,  1036 


INDEX 


1083 


Pancreas  cysts,   1035.     See  also  Cysts  of 
pancreas. 
degenerative  changes,  1050 
diabetes  and,  105 1 
diastatic  function,  Fedeli  and  Romani's 

test  for,  986 
diseases,  955 

acetonuria  in,  987 

alimentary  glycosuria  in,  988 

anamnesis,  993 

azotorrhea,  999 

azoturia  in,  987 

bile  in  urine  in,  987 

blood  coagulation  in,  992 
blood  in,  991,  998 

bowels  in,  999 

calcium  oxalate  in  urine  in,  988 

carbohydrates  in  urine  in,  988 

circulation  in,  999 

diagnosis,  993 

conditions  obscuring,  973 
use  of  enzymes  in,  983 

disturbance  of  appetite  in,  998 

dyspepsia  in,  998 

emaciation  in,  998 

fat  necrosis  in,  1000 

fat-splitting  ferment  in  urine  in,  991 

feces  in,  character,  986 
reaction,  986 

hemorrhage  in,  998 

history  of  case,  993 

indicanuria  in,  987 

jaundice  in,  997 

lipuria  in,  991 

liver  in,  999 

Loewis  test,  1047 

methods  of  diagnosis,  972 

nausea  in,  996 

pain  in,  994 

phosphaturia  in,  987 

physical  signs,  994 

pressure  symptoms  in,  998 

rigidity  in,  996 

Sahli's  test  in,  980 

Schmidt's  nuclei  test,  979 

sodium  fiuorid  fibrin  test  in,  980 

steatorrhea  in,  999 

symptoms,  993,  996 

temperature  in,  998 

tenderness  in,  995 

tumor  in,  994 

urinary  tests  in,  991 

urine  in,  changes,  987 

urobilin  in  urine  in,  987 

vomiting  in,  996 
of  blood  in,  997 
divisum,  959 
ducts,  958 

anatomic  variations,  960 

histology,  964 

terminations,  960 

variations,  960 
extirpation  of,  effect  on  fat  absorption, 

980 
fat  necrosis  of,  1029 
fatty  degeneration  of,  1050 
fibro-adenoma,  1049 


Pancreas,  focal  necrosis,  105 1 
frenum  carunculae,  958 
functional  disturbances  of,  1005 
functions,  temporary  disturbances,  972 

testing,  972 
head,  956 

hemorrhagic  necrosis,  1008 
histology,  964 
hyaline  degeneration,  1051 
inflammation,  acute  and  chronic,  classi- 
fication, 1002 
injuries,  loor 
interacinar     islands,     966.     See     also 

Islands  of  Langerhans. 
internal  secretion,  968 
laceration  due  to  direct  violence,  looi 
lesser,  956 

lymphadenoma,  1049 
lymphatics,  957 
meat,  Leube's,  191 
minus,  959 
neck,  956 
nerves,  957 
papilla  major,  958 
parvum,  959 

penetrating  wounds  of,  1002 
peritoneum,  958 
physiology,  964,  969 
plica  longitudinalis,  958 
pseudocysts  of,  1036 
sarcoma,  1048 
surgical  relations,  955,  961 
syphilis,  1031 

acquired,  103 1 
taU,  956,  957 
topography  of,  79 
tuberculosis  of,  1030 
tumors  of,  1044 
uncinate  process,  956 
veins,  957 
Pancreatic  achylia,  1005 

calculus,  103 1.     See  also  Calculus  pan- 
creatic. 
ferments,  970 

diastatic,  985 

direct  methods  of  obtaining,  973 
Einhom's  pump  for,  974 
Gross'  method,  973 

in  feces,  obtaining,  978 

indirect  methods  of  obtaining,  978 

use  of,  in  diagnosis,  983 
hemolysin,  992 
hemorrhage,  1008 
infantilism,  984,  1050 
juice,  969 

cause,  969 

ferments  of,  39 

function  of,  39 
reaction,  Cammidge,  988 
Pancreatitis,  acute,  1008 

Fitz's  classification,  1008 

hemorrhagic,   ioo8.     See  also  Hemor- 
rhagic pancreatitis. 

perforation  in  simple  duodenal  ulcer 
and,  differentiation,  745 

suppurative,  1015.    See  also  Suppura- 
tive pancreatitis. 


1084 


INDEX 


Pancreatitis,  chronic,  1018 

age  and,  1018 
•    anamnesis,  1022 

ascending  infection  from  duodenum 
as  cause,  1019 

blood  in,  1025 

bowels  in,  1025 

calculus  as  cause,  loig 

Canimidge  reaction  in,  1026 

cancer  of  pancreas  and,  differentia- 
tion, 1047 

cholecystotomy,  1028 

diagnosis,  differential,  1026 

diet  in,  1028 

digestive  symptoms,  1024 

duodenal  ulcer  and,   differentiation, 

751 
etiology,  1019 
feces  in,  1026 
gall-bladder  in,  1025 
gall-stones  and,  differentiation,  1027 
gastric  analysis  in,  1026 
infectious  diseases  as  cause,  1019 
interacinar,  102 1 
interlobular,  1020 

etiology,  1020 
jaundice,  1024 
liver  in,  1025 

malignant  growths  as  cause,  1019 
medicinal  treatment,  1028 
muscular  rigidity  in,  1025 
nausea  in,  1023 
pain  in,  1023 
pathology,  1020 
physical  examination,  in,  1025 
sex  and,  1018 
simulating  gastric  or  duodenal  ulcer 

with  pyloric  stenosis,  1022 
surgical  treatment,  1028 
symptoms,  1022 

sj'philis  and,  differentiation,  1027 
temperature,  1024 
tenderness  in,  1025 
treatment,  1028 
vomiting  in,  1023 
congenital  syphilitic,  1031 
etiology,  1003 
gangrenous,     acute,     1012.     See     also 

Gangrenous  pancreatitis. 
mumps  complicating,  1004 
subacute,  1013 
Papilla  major  of  pancreas,  958 
Papilloma  of  intestines,  780 
Paralysis  of  esophagus,  syphilitic,  62 
of  intestines,  901 
of  sphincters,  902 
Paramcecium  coli,  921 
Parasecretion,   386.     See  also  Gastrosuc- 

corrhea. 
Parasites  in  vomit,  157 

intestinal,  920 
Parasitic  ova,  examination  of  feces  for, 

542 
Paratyphlitis,  801  * 

Paratyphoid  bacillus,  706 
fever,  718 

complications,  720' 


Paratyphoid  fever,  course,  720 

diagnosis,  720 

etiolog)',  718 

incubation  period,  719 

mode  of  infection,  719 

pathology,  719 

prognosis,  720 

treatment,  720 
Parenteral  digestion,  42 

nutrition,  192 
Paresis,  intestinal,  871 
Parorexia,  472 
Passio  iliaca,  859 
Patient,  examination  of,  49 
history  of,  46 
interrogation  of,  46 

special,  in  diseases  of  intestines,  515 
Peanut  butter,  187 
Pea  sausage,  187 
Pea-soup  feces  in  typhoid,  704 
Pellagra,  stomach  functions  in,  503 
Pelvic  abscess,  798 

exudate  from  colon  bacillus  infection, 
600 
Pemphigus  of  mouth,  stomach  functions 

in,  507 
Pendulum  movements  of  large  intestine, 

44 
Penetrating  wounds  of  pancreas,  1002 
Penicillium  glaucum  in  gastric  contents, 

167 
Pengoldt  and  Faber's  test  for  absorptive 

power  of  stomach,  168 
Pepsin,  casein  test  for,  152 
in  gastric  contents,  150 
Mett's  test  for,  152 
ricin  test  for,  150 
Pepsinia,  normal,  151 
Pepsinogen,  34 
Peptic    ulcer,    277.     See    also    Ulcer    of 

stomach. 
Peptone  in  feces,  535 

in  gastric  contents,  150 
Percussion,  flicking,  72 
hammer,  71 
light,  71 
of  abdomen,  70 
of  gall-bladder,  77 
of  kidney,  87 
of  liver,  77 
of  spleen,  81 
of  stomach,  91,  135 
auscultatory,  92 

scratch  method,.  94,  95 
piano,  71 

simple  method,  71 
Percutaneous  method  of  applying  electric- 
ity in  stomach  diseases,  216 
Perforation  in  diverticulitis,  852 
in  intestinal  ulcer,  761 
in  simple  duodenal  ulcer,  742.     See  also 
Ulcer,  duodenal,  simple,  perfora- 
tion in. 
in  typhoid  fever,  702 

treatment,  715 
of  esophagus,  61  ' 

of  hernial  sac  in  diverticulitis,  853 


INDEX 


1085 


Perforative  appendicitis,  808 
Pericolic  membranes,  639 
Pericolitis,  637 

Peridiverticulitis,    839.     See    also    Diver- 
ticulitis. 
Perigastric  adhesions,  perigastritis   with, 

319 
Rontgen  rays  in  determmation  of,  1 29 
indirect  method,  132 
Perigastritis,    gastralgia  and,  differentia- 
tion, 478 
with  adhesions,  318 
diagnosis,  319 
treatment,  319 
Perisigmoiditis,  839.     See  also  Diverticu- 
litis. 
Peristalsis,  diagnostic  value  of,  67 
intestinal,  43 
nervous  control,  45 
visible,  67 
Peristaltic  restlessness  of  stomach,  480 
unrest,  900 

diagnostic  value,  67 
Peristole,  diminished,  398.     See  also  A  tony 

of  stomach. 
Peritoneal  coat  of  stomach,  19 
Peritoneum,   growths  of,  gastric   cancer 
and,  differentiation,  350 
of  pancreas,  958 
Peritonitis,  acute,  intestinal  obstruction 
and,  differentiation,  878 
adhesive,  in  amebic  dysentery,  682 
epigastric,  in  hemorrhagic  pancreatitis, 

1013 
in  typhoid  fever,  treatment,  715 
local  chronic,  from  diverticulitis,  853 
perforative,  diverticulitis  and,  differen- 
tiation, 855 
in  diverticulitis,  852 
Perityphlitis,  801 
Perversion  of  appetite,  472 
Petroleum,  absorption  of,  43 
Peyer's  patches,  27 
Phantom  tumor,  73,  585 
Pharj^nx,  inspection  of,  50 
Phenolphthalein  test  for    occult    hemor- 
rhage, 160 
Phlebectasia  hemorrhoidalis,  782 
Phlegmon,  ileac,  8oi 
Phlegmonous  enteritis,  665 

gastritis,  246.     See  also  Gastritis,  phleg- 
monous. 
Phloroglucin-vanillin  test  for  free  hydro- 
chloric acid,  144 
Phosphaturia  in  pancreatic  disease,  987 
Phosphorus  poisoning,  antidotes  for,  245 
Phthisis   ventriculi,    249,    250,    262.     See 

also  Achy  Ha  gastrica. 
Physical   examination,   general   methods, 

49 
Phytin  of  whole  wheat,  properties,  178 
Piano  percussion,  71 
Pica,  472 

Pig-head  tapeworm,  927 
Piles,  782.     See  also  Hemorrhoids. 
Pine-apple,  food  value  of,  178 
Pin- worm,  938 


Plexus,  Auerbach's,  24 

Meissner's,  24 
Plica  longitudinalis  of  pancreas,  958 
Plummer's     differential    4  diagnosis      of 
esophageal  stenosis  and  diverticu- 
"    lum,  52 
Pneumatosis,  485,  495 

cystoides  intestinorum  hominis,  781 
Pneumonia,  acute  atony  of  stomach  in, 

407 
Podophyllin  in  constipation,  622 
Poisons,  antidotes  for,  245 
Polyadenoma  of  stomach,  305.     See  also 

Stomach,  polyadenoma. 
Polyadenome  en  Nappe,  366 
Pol5T)hagia,  472 

Polyposis  gastrica,  365.     See  also  Stom- 
ach, polyadenoma. 

intestinalis  adenomatosa,  780 
Pork  tapeworm,  925 
Portal  vein,  thrombosis,  763,  766 
Postoperative  feeding,  195 
Powder-blower,  stomach,  214 
Pressure  paradox  in  chronic  dilatation  of 

duodenum,  636 
Priessnitz's  compress,  224 
Probilin  pills,  241 
Proctitis,  663 

classification,  663 

digital  examination  in,  664 

etiology,  663 

in  hemorrhoids,  797 

pathology,  663 

symptoms,  663 

treatment,  664 
Proctoclysis,  553,  563 

bottle,  heat-retaining,  563 

flatus  in,  564 

in  typhoid  fever,  714 

speed  of,  565 

vacuum  bottle  for,  563 
Proctoscope,  Kelly's,  518 

Tuttle's  pneumatic,  518 
Proctoscopy,  517 

Proctosigmoidoscope,      Tuttle's      pneu- 
matic, 521 
Proctospasmus,  612 
Prolapse  of  rectum  in  hemorrhoids,  793 
treatment,  795 

of  stomach,  89.     See  also  Gastroptosis. 
Propeptone  in  feces,  535 

in  gastric  contents,  150 
Prosecretin,  40,  969 
Protective  appendicitis,  808,  809,  824 
Protein  absorption,  573 

in  beans,  187 

diet,  17s 

metabolism,  175 
Protozoa,  920 
Protrusion  of  umbilicus,  diagnostic  value, 

67 
Pruritus  ani,  799 
Pseudo-angina    with     acute     ectasy     of 

stomach,  406 
Pseudocysts  of  pancreas,  1036 
Pseudomembranous  enteritis,  905 
Psoriasis,  stomach  functions  in,  507 


io86 


INDEX 


Psorospermiasis,  920 
Ptyalin,  33 

Pxilse  in  typhoid  fever,  703 
Purulent  appendicitis,  805,  807 

enteritis,  665 
Pus  in  feces,  533,  541 

in  intestinal  cancer,  775 
ulcer,  761 
gastric  cancer,  338 
in  vomit,  157 

microscopic,  in  hj'perchlorhydria,  376 
Putrefaction,  intestinal  chronic,  573 

combined  indolic  and  saccharobuty- 

ric,  578 
saccharobutyric  type,  578 
Putrefactive  products  in  feces,  tests  for, 

550. 
Pyelitis,   Bacillus  coli  infections  of  kid- 
neys in,  598 
Pyemia  after  typhoid  fever,  705 
Pyloric  glands  of  stomach,  20 
Pylorospasmus,  482 

Einhorn's  pyloric  dilator  for,  484 
Rontgen  rays  in,  484 
symptoms,  483 
treatment,  484 
surgical,  484 
Pylorus,  17 

congenital  narrowing,  437 
incontinence  of,  481 
insufficiency,  481 
snail-form,  in  gastric  ulcer,  290 
spasm,  482 

stenosis  of,  laparotomy  in,  351 
syphilitic,  509 

gastric  cancer  and,  differentiation, 
346 
Pyrosis,  489 
in  simple  acute  gastritis,  treatment,  239 

Radiodiaphane,  134 
Radium  introducer,  357 

photographs  of  stomach,  135 

transillumination  of  stomach,  134 

treatment  of  gastric  cancer,  357 
Ranula  pancreatica,  1035 
Raspberry  tongue,  50 
Rectal  alimentation,  191 

examination,  digital,  69 

infusion,  565 

irrigator,  Kemp's,  557 

obturator,  904 
Recti  muscles,  palpation  of,  69 
Rectum,  31 

abscess  of,  797 
superficial,  797 

anesthesia  of,  903 

arterial  supply,  31 

cancer  of,  776 

examination,  in  appendicitis,  815 
in  chronic  enteritis,  653,  658 

inspection,  517 

lymphatics,  32 

nerves,  32 

palpation,  524 
by  sounds,  525 

prolapse,  in  hemorrhoids,  793 


Rectum,  prolapse,  treatment,  795 

veins,  31 
Recurrent  vomiting  in  children,  492 
Reduction  in  obesity,  diet  for,  916 
Reflex  vomiting,  494 
Reflexes  in  typhoid  fever,  703 
Regulin  in  constipation,  621 
Regurgitation,  duodenal,  from  fatty  food, 
482 
of  food,  489 
Reichmann's  disease,  386,  391.     See  also 
Gastrosuccorrhea . 
method  of  examining  contents  of  fasting 

stomach,  157 
rod,  94 
Renal  calculi,  gastralgia  and,  differentia- 
tion, 478 
insufficiency   in   typhoid   fever,    treat- 
ment, 717 
Rennet,  152 
absence  of,  152 
deficient,  152 
normal,  152 
Rennet-zymogen,  34,  153 
Resorcin-sugar  test  for  free  hydrochloric 

acid,  144 
Respiratory  organs  in  typhoid  fever,  702 
Retention  cysts  of  pancreas,  1035 
Rhabdonema  intestinale,  948 
Rheumatism,  gastralgia  and,  differentia- 
tion, 477       . 
Rhubarb  in  constipation,  622 
Ricin  test  for  pepsin,  151 
Riegel's  test-dinner,  136 

test  for  free  hydrochloric  acid,  154 
Rigidity  in  pancreatic  diseases,  996 

muscular  in  chronic  pancreatitis,  1025 
Ringing  sounds  of  stomach,  99 
Roberts'  rectal  speculum,  glass,  518 

sphincter  dilator,  791 
Robson  and  Cammidge's  test  for  fat  in 
feces,  982 
classification  of  acute  and  chronic  in- 
flammation of  pancreas,  1002 
Rod,  Reichmann's,  94 
Rogers'  red  dots  in  amebic  dysentery,  670, 

672 
Roller  massage,  223,  224 
Rontgeno-cinematographic  method  of  di- 
agnosis, 113 
Rontgen-ray  diagnosis  of  cancer  of  stom- 
ach, 125 
of  chronic  appendicitis,  825 
findings  in  duodenal  ulcer,  1 18-124 
for  detecting  foreign  bodies  in  stomach, 

.     "3. 

of  gastric  ulcer,  289 

of  hour-glass  stomach,  123 

in  gastric  ulcer,  114-118 
for  determining  gall-stones,  132 
gastroptosis,  124,  126 
hyperistalsis,  126 
perigastric  adhesions,  129 
indirect  method,  132 
position  of  stomach,  123 

for  enteroptosis,  124 

in  chronic  intestinal  obstruction,  886 


INDEX 


1087 


Rontgen-ray   in   determining  diseases  of 
stomach,  135 
in   diagnosis  of  cancer  of  stomach, 
filling  defects  in,  126 
of  cholecystitis,  132 
of  diseases  of  esophagus,  113,  114 
of  stomach,  113 
technic,  114 
of  div-erticulitis,  855 
of  gastric  cancer,  342 
of  intestinal  cancer,  777 
of  pancreatic  calculi,  1032 
of  stomach  diseases,  135 
in  diaphragmatic  hernia,  440 
in  examination  of  esophagus,  56   » 

of  intestines,  528 
in  gastric  sj'philis,  510 

ulcer,  289 
in  gastroptosis,  461 
in  hour-glass  stomach,  438 
in  Jackson's  membrane,  638 
in  jejunal  ulcer,  313 
in  pylorospasmus,  484 
in  simple  duodenal  ulcer,  736 
in  stenotic  ectasy  of  stomach,  424 
in  treatment  of  gastric  cancer,  356 

ulcer,  309 
location  of  colon  \vith,  529 
physiologic  investigations  with,  529 
Rosenthal-Leube's  method  of  lavage,  205 
Roser  position  for  esophagoscopy,  loi,  102 
Rose's  adhesive  plaster  belt,  226-229 

in  atonic  ectasy  of  stomach,  428 
in  gastroptosis,  461,  462 
method  of  making,  228-230 
carbonic  acid  gas  generator,  530 
Rosewater  adhesive  belt,  230,  234 
Rotation  method  of  intestinal  irrigation, 

569 
Round  worm,  935 
Rovsing-Chase   method   of  palpation   in 

appendicitis,  814 
Rumination,  490 
Russell's  treatment  of  gastroptosis,  405 

Saccharobutyric  type  of  intestinal  putre- 
faction, 578 
indolic  type  with,  578 
Sago  grains  in  chronic  enteritis,  654 
Sahli's  desmoid  test  of  gastric  juice,  155 

test  in  diseases  of  pancreas,  980 
Salol  test  of  motor  power  of  stomach,  1 70 
Salomen's  test  in  cancer  of  stomach,  341 
Sand,  intestinal,  593 
Santorini,  duct  of,  958 
Sapremia,  intestinal,  613 
Sarcinje  in  gastric  contents,  166 
Sarcoma  of  intestines,  778 
of  pancreas,  1048 
of  stomach,  363 

average  duration,  364 
gastric  analysis  in,  364 
symptoms,  364 
treatment,  364 
Scale,  diet,  185,  186 
Leube's  diet,  186 
Schistosoma  haematobium,  931 


Schmidt-Stokes  milk-tube,  982 
Schmidt-Strassburger    fermentation    test 
of  feces,  549 
test-diet  to  determine  intestinal  func- 
tions, 544 
Schmidt's  test  for  nuclei,  979 

treatment  of  gastric  ulcer,  304 
Sclerosis  of  stomach,  gastric  cancer  and, 
differentiation,  345 
ventriculi,  249,  250 
Scolecoiditis,  801 
Seat-worm,  938 
Secretin,  969 
Secretogogues,  35 

Secretory  neuroses  of  intestines,  905 
Senator's  treatment  in  gastric  ulcer,  304 
Senile  dyspepsia,  590.    See  also  Dyspepsia, 

senile. 
Sensations  within  stomach,  473 
Septicemia  after  typhoid  fever,  705 
Serous  coat  of  small  intestine,  24 
Serum  therapy  in  bacillary  dysentery,  699 
Sham  feeding,  effect  on  secretion  of  gastric 

juice,  35 
Sialorrhoea  pancreatica,  999 
Siever   and   Ewald's  salol  test  of  motor 

power  of  stomach,  1 70 
Sigmoid  flexure,  31 
dilated,  641 

diverticula  of  intestines  and,  848 
volvulus  of,  865 
Sigmoiditis,  839.     See  also  Diverliculitis. 
diverticulitis  and,  differentiation,  855 
Sigmoidoscope,  Strauss',  519,  522 

Tuttle's,  519 
Sigmoidoscopy,  517,  519,  522 
Silica  metabolism  in  gastric  cancer,  341' 
Silver  nitrate  poisoning,  antidotes  for,  245 
Sims'  rectal  speculum,  519 
Singultus  gastricus  nervosus,  488 
Sippy's  treatment  of  gastric  ulcer,  304 
Sitophobia,  475 
Siturgy,  473 

Sizzling  sounds  in  stomach,  97,  99 
Skatol  in  feces,  test  for,  550 
Skin  diseases,  stomach  functions  in,  506 
Smithies'  percussion  sign  in  gastric  cancer, 

Smoking  m  chronic  gastritis,  257 
Sodium  benzoate  in  duodenitis  with  jaun- 
dice, 651 
fluorid  fibrin  test  in  diseases  of  pancreas, 

980 
iodid  in  gastric  cancer,  358 
Solitary  follicles  of  small  intestine,  27 
Solms-Jacoby  test  for  pepsin,  151 
Sounds,  esophageal,  use  of,  55 
splashing,  in  esophagus,  51 
Soy  bean,  179 
flour,  179 
broths,  180 
gruels,  180 
muffins,  180 
Spasm  of  cardia,  485 
of  pylorus,  482 
of  sphincter  ani,  612 
treatment,  624 


io88 


INDEX 


Spastic  constipation,  612 

hour-glass  stomach,  439 
Spectroscopic  blood-examination,  clinical, 

technic,  584 
Speculum,  Kelly's  sigmoid,  518 
rectal,  Gant's  examining,  520 
hinged,  520 
Kelly's  short,  517 

standard,  517 
Kelsey's,  519 
Roberts'  glass,  518 
Sims',  519  * 

Sphincter  ani  dilatation  for  hemorrhoids, 
791 
internal,  31 
paralysis,  903 
spasm,  612 
treatment,  624 
antri,  37 
Spider  gall-bladder  adhesions,  gastric  ulcer 

and,  differentiation,  294 
Spilling,  69 
liver,  76 
spleen,  80 
Splanchnoptosis,  422.     See  also  Gastrop- 

tosis. 
Splashing  sounds  in  acute  ectasy  of  stom- 
ach, 410 
in  esophagus,  51 
in  gastroptosis,  449 
in  hyperchlorhydria,  373 
in  intestinal  diseases,  523 
of  stomach,  98,  135. 
Spleen,  abscess  in,  in  amebic  dysentery, 
677 
acute  enlargement,  82 
dulness,  82 
floating,  82 
in  typhoid  fever,  707 
inspection  of,  80 
movable,  460 
palpation,  80 
percussion  of,  81 
physical  examination,  80 
spilling,  80 
topography  of,  80 
Splenic  flexure  of  transverse  colon,  30 
Sponging  in  typhoid  fever,  712 
Spool  worm,  935 
Sporozoa,  920 
Spray,   gastric,    214.     See   also   Stomach 

spray. 
Sprue  after  amebic  dysentery,  683 
Starch,  digested,  examination  of,  153 

in  feces,  535 
Stasis,  chronic  intestinal,  630 
etiology,  631 
treatment,  633 
Static  electricity  in  stomach  diseases,  219 
Steapsin,  39,  970 

examination  for,  976,  977 
in  gastric  contents,  158 
Steatorrhea,  537,  981 
color  of  feces  in,  983 
in  pancreatic  diseases,  999 
Steele's  diet  to  test  intestinal  functions, 
544 


Stenosis,   duodenal,   with  motor  disturb- 
ances and  dilatation  of  stomach, 
treatment,  754 
of  cardia,  treatment,  363 
of  esophagus,  diverticulum  of  esophagus 

and,  differentiation,  52 
of  pylorus,  gastralgia  and,  differentia- 
tion, 477 
laparotomy  in,  351 
syphilitic,  509 

gastric  cancer  and,  differentiation, 
346 
of  stomach,  gastric  cancer  and,  differ- 
entiation, 348 
Stenotic  ectasia  of  stomach,  419 
Stercobilin  in  feces,  536 
Stercoral  ulcer  of  intestines,  758 
Stereoradiography  in  diseases  of  stomach, 

114 
Stewart's  method  of  continuous  intestinal 

irrigation,  559 
Stomach,  abnormal  sensations  in,  474 
abscess    of,    246.     See    also    Gastritis, 

phlegmonous. 
absorptive  function,  determination,  168 
acute  diseases  of,  diet  in,  192 
adenocarcinoma  of,  324 
anatomy,  17 

anomalies  in  position  and  form,  437 
antiperistaltic  restlessness  of,  481 
arteries,  20 
atony,    398,   485.     [See   also   Atony  of 

stomach. 
atrophy  of,  250,  262.     See  also  Achylia 

gastrica. 
auscultatory  percussion  of,  92 

stratch  method,  94,  95 
bacteria  in,  34 
blood-vessels,  20 
bubbling  sounds  in,  97 
cancer    of,    320.     See    alio    Cancer    of 

stomach. 
capacity,  19 
cardiac  glands,  20 

orifice,  17 
catarrh  of,  236.     See  also  Gastritis. 
chronic  diseases  of,  diet  in,  193 
cirrhosis,  syphiUtic,  511 
coats,  19 

contents,   analysis,   in  chronic  pancre- 
atitis, 1026 
in  senile  dyspepsia,  590 
in  simple  duodenal  ulcer,  739 
cul-de-sac  of,  greater,  17 
deglutition  sounds  of,  99 
determining  lower  margin  of,  97 

position  of,  DeMo's  method,  135 
digestion,   fractional   study,   by  inter- 
mittent aspiration,  137 
dilatation,    401.     See    also    Ectasy    of 

stomach. 
diseases,  89 

cold  applications  in,  224 
counterirritation  in,  225 
douche  in,  225 

electricity  in,    216.     See  also  Elec- 
tricity in  stomach  diseases. 


INDEX 


1089 


Stomach  diseases,  hot  applications  in,  224 

hydrotherapy  in,  224 

moist  heat  in,  224 

orthopedic  treatment,  225 

Rontgen  rays  in  diagnosis  of,  135 
dislocation,  439 
douche,  211 

alternate  hot  and  cold,  213 

bulb-compression  method,  212 

double-current,  212 

Gross'  double  current,  212 

in  atonic  ectasy  of  stomach,  429 

medication  by,  212 

technic,  212 

temperature  of  fluid,  212 

Y-method,  212 
drain-trap,  37 
dripping  sounds,  99 

ectasy,  401.     See  also  Eclasy  of  stom- 
ach. 
electrode,  Bassler's  218 
epithelioma  of,  324 
erosions,  315 
esophageal  orifice,  17 
examination,  Knapp's  method,  90 

preparation  of  patient,  90 
fasting,  examination  of  contents,  157 

Reichmann's   method   of   examining 
contents,  157 
fish-hook,  37,  120,  121,  455 
fore-,  437    . 
foreign  bodies  in,  367 

Rontgen  rays  for  detecting,  113 
functional  diseases,  370 
functions,  examination,  136 

eye  diseases  in,  506 

heart  lesions  in,  504 

in  acne  rosacea,  506 

in  acne  simplex,  506 

in  acute  febrile  diseases,  501 

in  anemia,  503 

in  aneurysm,  504 

in  arteriosclerosis,  506 

in  arthritis  deformans,  505 

in  chlorosis,  503 

in  chronic  febrile  diseases,  502 

in  diabetes,  505 

in  ear  diseases,  506 

in  eczema,  506 

in  erythema,  507 

in  gout,  505 

in  grip,  505 

in  kidney  diseases,  504 

in  liver  diseases,  504 

in  malaria,  505 

in  nose  diseases,  506 

in  pellagra,  503 

in  pemphigus  of  mouth,  507 

in  psoriasis,  507 

in  pulmonary  tuberculosis,  502 

in  skin  diseases,  50b 

in  throat  diseases,  506 

in  urticaria,  507 

motor,  36,  169 

Ewald  and  Siever's  test,  170 
Hemmeter-Moritz  test,  171 
iodipin  test  for,  171 

69 


Stomach  functions,   motor,    Klemperer's 
oil  test  for,  171 
Mathieu-R^mond  test,  170 
salol  test  of,  170 
test-breakfast  for,  169 
test-meal  for,  169 
test-supper  for,  169 
tests  for,  169 
sensation,  136 
fundus,  17 

glands,  20 
gastralgia  originating  in,  476 
gastric  insufl&ciency,  399 
glands,  20 

greater  curvature,  18,  89 
gurgling  sound  of,  99 
Head's  zones  for,  830 
hemorrhage,  250.     See  also  Hemorrhage 

of  stomach. 
hour-glass,  437.     See    also    Hour-glass 
stomach. 
in  gastric  ulcer,  118 
Rontgen  rays  for  determining,  123 
hyperesthesia  of,  474 
hypermotility  of,  479 
inflammation  of,  suppurative,  246.     See 

also  Gastritis,  phlegmonous. 
inflation  of,  135 
mth  air,  96 
with  water,  96 
with  carbonic  acid  gas,  95 
inspection  of,  90,  135 
lavage,  196.     See  also  Lavage. 
lesser  curvature,  18 
lymphatics,  21 

massage,  221.     See  also  Massage. 
methods  of  physical  examination,  89 
motility,  37 

motor  insufl&ciency,  399 
of  first  degree,  399 
of  second  degree,  414 
mucous  coat,  20 

glands,  20 
multiple  polypi  of,  undergoing  malignant 

changes,  363 
muscular  coat,  19 
nerves,  22 

nervous  affections,  469 
neuralgia  of,  475 

neuroses,    469.     See    also    Neuroses  of 
stomach. 
secretory,  495 
normal  capacity,  415 
palpation  of,  91,  135 
percussion  of,  91,  135 
peristaltic  action  of,  169 

restlessness  of,  480 
peritoneal  coat,  19 
polyadenoma,  365 
age  in,  365 
diagnosis,  366 
etiology,  365 
location,  366 
pathology,  365 
symptoms,  366 
treatment,  366 
position,  17 


logo 


INDEX 


Stomach  position,  determining,  94-98 
Dehio's  method,  96 
Leube's  sound  method,  97 
Rontgen  rays  for,  123 
powder-blower,  214 

Einhom's,  215 
prolapse,  89.     See  also  Gastroptosis. 
pulsation  in,  474 
pyloric  glands,  20 
radium  photographs  of,  135 
transillumination  of,  134 
'  resonance,  dorsal  nucleus  of,  92 
ringing  sounds  of,  99 
Rontgen  rays  in  diagnosis  of  diseases  of, 

"3 
sarcoma  of,  363.     See  also  Sarcoma  of 

stomach. 
secretion,  examination  of,  136 
sensations  within,  473 
shape,  37 

sizzling  sounds  in,  97,  99 
snail  form,  116 

sparing,  method  of  feeding  for,  189 
spasm,  475 

intestinal  splash  and,  differentiation, 
98 
splashing  sounds  of,  98,  135 
spray,  214 

Einhom's  tube  for,  214 

in  atonic  ectasy  of  stomach,  429 

gastrosuccorrhea  continua  chronica, 
.396 

indications  for,  208  » 

technic,  214 
stenosis,  gastric  cancer  and,  differentia- 
tion, 348 
stiffenings  of  Cohnheina,  67 
stricture,  diet  in,  193 
structure,  19 
submucous  coat,  20 
succussion  sound  of,  99 
supermotility,  479 
syphilis,  508 

Rontgen  rays  in,  510 
transillumination,  109 
treatment,  local,  196 
tuberculosis,  anatomic  types,  507 
tumors,  363 

apparent,  344,  366 

benign,  365   ,  . 

differential  diagnosis,  94 

syphilitic,  509 
ulcer,  277.     See  also  Ulcer  of  slomach. 

deformity  of  contour  in,  117 

hour-glass  contraction  in,  118 
ulceration  of,  superficial,  314 
undershot,  116 
veins,  21 
vertical,  451 
volume,  18 
volvulus  of,  441 
water-trap,  37,  456,  457 
weak,  236 
Stomachics  in  chronic  gastritis,  259 
Stomach-tube  for  lavage,  selection,  197 
Stomach- whistle,  Kemp's,  97 
Stools.    See  Feces, 


Stozyzowski's  modification  of  Teichmann's 

test  for  hemin  crystals,  162 
Strangulation  by  herniae,  internal,  860,  86 1 
by  Meckel's  diverticulum,  861 
clinical  symptoms,  864 
hemiaform  internal,  mechanism,  863 
through  apertures,  861 
through  slits,  861 
Strassburger's  fermentation  tube,  549 
Strauss'  mixing  funnel,  149 

sigmoidoscope,  519,  522 
Strawberry  tongue,  50 
Streptothrix  Foersteri  in  gastric  contents, 

167 
Strictureof  duodenum,  duodenal  ulcer  and, 
differentiation,  749 
of  esophagus,  62 

benign,  examination,  54 
thiosinamin  in,  59 
treatment,  59 
malignant,  examination,  55 
of  rectum,  chronic  intestinal  obstruc- 
tion from,  888 
of  stomach,  diet  in,  193 
Strongyloides  intestinalis,  948 
Strongylus  duodenalis,  940 
Subacute  pancreatitis,  1013 
Subinfection,  571 
Sublimate  test  for  bile-pigment  in  feces, 

549 
Submucous  coat  of  small  intestine,  25 

of  stomach,  20 
Subphrenic    abscess    from  co  on  bacillus 
infection,  602 
terminations  of,  288 
Succus  entericus,  40 
Succussion  sound  in  intestinal  diseases, 

523 
sound  of  stomach,  99 
Sugar,  absorption  of,  42 
in  feces,  535 
milk-,  absorption  of,  42 
Superacidity,  370 
Supermotility  of  stomach,  479 
Supporter,  Lane's  abdominal,  235 
Suppurative  appendicitis,  805 
acute,  807 
diagnosis,  1017 
etiology,  1016 
pathology,  1015 
sequelae,  1016 
symptoms,  1016 
treatment,  1017 
Suprahepatic  ballottement,  78 
Sutton's   method   of  intestinal   inflation, 

.531      .       . 
Sweet  oil  injection  in  constipation,  620 
Sympatheticotonia,  892 
etiology,  893 
symptoms,  896 
treatment,  896 
Syncongestive  appendicitis,  809 
Syphilis,  chronic  pancreatitis  and,  differ- 
entiation, 1027 
gastric  cancer  and,  differentiation,  345 
of  pancreas,  1031 

acquired,  1031  * 


INDEX 


togt 


Syphilis  of  stomach,  508 

Rontgen  rays  in,  510 
Syphilitic  cirrhosis  of  stomach,  511 
pancreatitis,  congenital,  103 1 
paralysis  of  esophagus,  62 
stenosis  of  pylorus,  509 
tumor  of  stomach,  509 
ulcers  of  intestines,  759 
of  stomach,  509 

Tabes,  gastralgia  and,  differentiation,  477 

gastric  crises  of,  512 
Ttenia  cucumerina,  928 

echinococcus,  928 

elliptica,  928 

flavopunctata,  928 

lata,  927 

Madagascariensis,  928 

mediocanellata,  924 

nana,  928 

saginata,  926 

solium,  924,  925 
Tamarinds  in  constipation,  622 
Tapotement  in  massage,  221 
Tapeworm,  924 

armed,  925 

beef,  926 

description,  925 

pig-head,  927 

pork,  925 

treatment,  929 

unarmed,  926 
Tapping  in  massage,  221 
Tartar  emetic  poisoning,  antidotes  for,  245 
Tea  in  test-meal,  138 
Teichmann's  test  for  hemin  crystals,  162 
Stozyzowski's  modification,  162 
Temperature  in  acute  appendicitis,  815 

in  chronic  pancreatitis,  1024 

in  gastric  cancer,  332 

in  pancreatic  diseases,  998 

in  typhoid  fever,  703,  712 
Tenderness  in  chronic  pancreatitis,  1025 

in  pancreatic  diseases,  995 
Tenesmus  in  acute  amebic  dysentery,  679 

in  amebic  dysentery,  680 

carbonic  acid  gas  for,  691 

in  bacillary  dysentery,  treatment,  698 

in  hemorrhoids,  785 
Test-breakfast,  Boas',  137 

Ewald  and  Boas',  137 

for  motor  power,  169 

in  gastric  cancer,  336 

in  stenotic  ectasy  of  stomach,  424 
Test-diet,  examination  of  feces  after,  545- 

.     551     . 
Test-dinner,  Riegel's,  136 
Test-meal,  136 

dry,  137 

Ewald's,  136 

Germain  S6e's,  137 

Klemperer's,  137 

Leube's,  for  motor  power,  169 

making  diagnosis  from,  138 

precautions  before,  138 

tea  in,  138 
Test-supper  for  motor  power,  169 


Tetany,  acute  ectasy  of  stomach  in,  406 
gastrosuccorrhea  continua  chronica  and, 

differentiation,  394 
in  ectasy  of  stomach,  433 

Chvostek's  symptom,  434 
diagnosis,  434 
Erb's  sign  in,  434 
etiology,  433 
frequency,  434 
Hoffmann's  sign  in,  434 
pathology,  433 
prognosis,  434 
symptoms,  434 
treatment,  434 
Trousseau's  symptom,  433 
in  gastric  cancer,  332 

tetany,  Erb's  sign  in,  434 
in  simple  duodenal  ulcer,  741 
Thimble  gag  for  esophagoscopy,   102 
Thiosinamin  in  benign  stricture  of  eso- 
phagus, 59 
in  gastric  cancer,  358 
Thirst  in  gastric  ulcer,  treatment  287 
in  gastrosuccorrhea  continua  periodica, 
treatment,  390 
Thoracic   disease,    acute,  perforation  in 
simple  duodenal  ulcer  and,  diff- 
erentiation, 741 
Thread-worm,  938 

Throat  diseases,  stomach  functions  in,  506 
Thrombosis  in  cancer  of  stomach,  332 
in  typhoid  fever,  705 
of  inferior  mesenteric  artery,  756 
of  mesenteric  arteries,  763 
clinical  symptoms,  756 
diagnosis,  756 
etiology,  763 
prognosis,  756 
vems,  763 
etiology,  763 
treatment,  766 
Thrombotic  intestinal  ulcers,  755 
Thymol  in  uncinariasis,  947 
Thymus  extract  in  gastric  cancer,  361 
Thyroid  extract  in  gastric  cancer,  361 
Tongue,  inspection  of,  49 
raspberry,  50 
strawberry,  50 
Tonsils,  inspection  of,  50 
Topfer's  test  for  combined  hydrochloric 
acid,  146 
for  free  hydrochloric  acid,  145,  146 
for  total  hydrochloric  acid,  146 
Tormina  intestinorum,  900 

ventriculi  nervosa,  480 
Toxic  gastritis,   243.     See  also  Gastritis, 
toxic. 
ulcers  of  intestines,  759 
Transillumination  in  gastric  cancer,  332 
of  intestines,  528 
of  stomach,  log 
radium,  134 
Traube's  space,  19 
Trematodes,  930 

Tremoliere's   solution  for  hemorrhage  in 
amebic  dysentery,  691 
in  gastric  cancer,  362 


I092 


INDEX 


Trichina  spiralis,  950 

in  cerebrospinal  fluid,  951 
in  muscle,  950 
toxins  from,  952 
Trichinella  spiralis  in  blood,  951 
Trichiniasis,  950 

differential  diagnosis,  953 
incidence,  950 
prognosis,  953 
prophylaxis,  953 
symptoms,  952 
treatment,  953 
Trichocephalus  dispar,  949 
Trichomonas  hominis  in  gastric  contents, 
164 
intestinalis,  921 
Triphase  method  of  applying  electricity 

in  stomach  diseases,  219 
Tropaolin  00  test    for    free    hydrochloric 

acid,  153 
Trousseau's  symptom  in  gastric  tetany, 

434 
Trypsin,  39,  970 

examination  for,  977  978 

Miiller's  serum  plate  method,  979 
in  feces,  test  for,  537 
in  gastric  contents,  158 
treatment  of  gastric  cancer,  359 
Tryptophan  test  in  gastric  cancer,  338 
Tubercle  bacilli  in  feces  in  intestinal  ulcer, 

761 
Tubercular  ulcers  of  intestines,  secondary, 

757 
Tuberculosis,  ileocecal,  Head's  zones   in, 

833 
intestinal,  757 
of  pancreas,  1030 
of  stomach,  anatomic  types,  507 
pulmonary,  stomach  functions  in,  502 
Tuberculous  diaphragmatic  pleurisy,  gas- 
tric ulcer  and,  differentiation,  294 
Tubular  diarrhea,  905 
Tumors,  fecal,  614 
fragments  in  feces,  541 
in  intussusception,  869 
left-sided,  in  diverticulitis,  854 
of  intestines,  767 

benign,  779 
of  pancreas,  1036,  1044 
of   stomach,    363.     See   also   Stomach, 

tumors  of. 
phantom,  73,  585 
Tiirck's  colonic  nebulizer,  565,  566 

double-current  needle  douche  for  sig- 
moid, 565 
gyromele,  219,  220 
Tuttle's  pneumatic  proctosigmoidoscope, 

5.21 
sigmoidoscope,  519 
Tympanites,  584 
etiology,  584 

in  typhoid  fever,  treatment,  714 
flank,  874 
hystericus,  585 

in  chronic  intestinal  obstruction,  886 
nervous,  585 
prognosis,  586 


Tympanites,  symptoms,  585 

treatment,  586 
Typhlitis,  801 
Typhoid  fever,  700 

acute  ectasy  of  stomach  in  alcohol  in, 
716 

autogenous  vaccines  in,  71S 

bacilluria  in,  treatment,  717 

Bacillus  coli  infections  of  kidneys  in, 
.598 

bacillus  typhosus  as  cause,  700 

baths  in,  712 

bladder  in,  702 

blood  in,  705 

bone-marrow  in,  702 

bowels  in,   712 

Brand  treatment,  712 

carriers,  708,  717 

chart,  703 

chronic  distribution,  708 

circulatory  changes  in,  702 

colitis  in,  treatment,  717 

convalescence,  717 

diagnosis,  705 

diarrhea  in,  treatment,  715 

diet  in,  708 

disinfection  in,  708 

Ehrlich's  diazo-reaction  in,  705 

etiology,  700 

from  infected  oysters,  707  . 

gall-bladder  in,  702 

gelatin  in,  710 

headache  in,  treatment,  717 

healing  of  intestines  in,  702 

heart  stimulants  in,  715 

hemorrhage  in,  death  from,  702 
treatment,  715 

history,  700 

hypoleukocytosis  in,  705 

immunity  to,  700 

insomnia  in,  treatment,  717 

intestinal  hyperplasia  in,  701 

intestines  in,  701 

irrigation  in,  710 

kidneys  in,  702 

leukopenia  in,  705 

liver  in,  702 

mesenteric  glands  in,  702 

milk  in  709,  712 

modes  of  conveyance,  701 

modes  of  onset,  704 

morbid  anatomy,  701 

mortality  in,  706 

necrosis  in,  702 

nervous  symptoms  in,  703 
treatment,  717 

neuritis  in,  705 

osseous  system  in,  702,  705 

pea-soup  feces  in,  704 

perforation  in,  702 
symptoms,  705 

/^   treatment,  715 

peritonitis  in,  treatment,  715 

precautions  in,  708 

proctoclysis  in,  714 

prognosis,  706 

prophylaxis,  706 


INDEX 


1093 


Typhoid  fever,  pulse  in,  703 
pyemia  after,  705 
reflexes  in,  703 

renal  insufficiency  in,  treatment,  717 
respiratory  organs  in,  702 
septicemia  after,  705 
spleen  in,  702 
sponging  in,  712 
symptoms,  703 
temperature  in,  703,  712 
tlirombosis  in,  705 
treatment,  708 

medicinal,  713 
tympanites  in,  treatment,  714 
ulceration  in,  702 
vaccination  against,  707 
vaccine  therapy  in,  713 
voluntary  muscles  in,  703 
Widal's  reaction  in,  706 
Typhus,  mild  endemic,  720 

complications,  721 

diagnosis,  721 

etiology,  721 

history,  720 

incubation  period,  721 

method  of  transmission,  721 

prognosis,  723 

symptoms,  721 

treatment,  723 

Uffelmann's  test  for  lactic  acid,  148 

modified,  148 
Ulcer,  cancerous,  of  intestines,  757 
catarrhal,  of  intestine,  758 
classic  or  undermined  in  amebic  dysen- 
tery, 672 
decubital,  of  intestines,  758 
duodenal,  724 
acute,  735 
chronic,  725,  735 

gastric  ulcer  and,  differentiation,  294 
perforating,  725 

Rontgen-ray  findings  in,  1 18-124 
round,  725 
simple,  725 

achlorhydria    haemorrhagica    gas- 

trica  and,  differentiations,  751 
acid  gastritis  and,  differentiation, 

751 
age  and,  727 
Banti's  disease  and,  differentiation, 

752 
blood  examination  in,  739 
bowels  in,  739 
cardiospasm  in,  741 
characteristics,  728 
cholelithiasis   and,    differentiation, 

751.  ■ 
chronic  appendicitis  and,  differen- 
tiation, 750 
pancreatitis  and,  differentiation, 

perforation  in,  treatment,  754 
clinical  aspects,  734 
collapse  in,  treatment,  753 
complications,  732 
contact,  732 


Ulcer,  duodenal,  simple,  diagnosis,  750 
differential,  748 
diet  in,  753 
etiology,  725 
frequency,  726 

gastric  ulcer  and, differentiation,  750 
hemorrhage,  740 

Kemp's  treatment,  752 
treatment,  752 
hyperchlorhydria  and,  differentia- 
tion, 7  so 
hyperchlorhydria  in,  treatment,  753 
jaundice  in,  741 
kissing,  732 
medical  treatment,  753 
number,  732 
pain  in,  736 
pathology,  728 
perforation  in,  742 

acute    pancreatitis   and,    differ- 
entiation, 745 
perforation  of  gall-bladder  and, 

differentiation,  745 
thoracic  disease  and,  differen- 
tiation, 746 
chronic,  747 
perforation  in  gastric  ulcer  and, 

differentiation,  744 
subacute,  747 
symptoms,  743 
treatment,  746 
prognosis,  752 
recurrences,  732 
Rontgen  rays  in,  736 
sex  and,  728 
site,  731 
stomach  contents  in,  739 

dilatation  in,  741 
stricture  of  duodenum  and,  differ- 
entiation, 749 
surgical  treatment,  753 
symptoms,  735,  736 
tetany  in,  741 
treatment,  752 

ulceration  of  gall-stone  into  duo- 
denum and,  differentiation,  751 
embolic,  of  intestines,  755 
follicular,  of  intestines,  758 
gonorrheal,  of  intestines,  759 
jejunal,  313 
etiology,  313 
symptoms,  313 
treatment,  314 
ac-rays  in,  313 
of  esophagus,  61 
diagnosis,'6i 
etiology,  61 
symptoms,  61 
treatment,  62 
of  intestines,  724 
blood  in,  761 

feces  in,  761 
cancerous,  757 
catarrhal,  758 
decubital,  758 

diarrhea  in,  760  • 

embolic,  755 


1094 


INDEX 


Ulcer  of  intestines,  fever  in,  761 
follicular,  758 
from  cutaneous  bums,  754 
general  nutrition  in,  761 
gonorrheal,  759 
mucus  in  feces  in,  761 
pain  in,  761 
perforation  in,  761 
pus  in  feces  in,  761 
stercoral,  758 
symptoms,  760 
syphilitic,  759 
thrombotic,  755 
tissue  threads  in  feces  in,  761 
toxic,  759 
treatment,  762 

tubercle  bacilli  in  feces  in,  761 
tubercular,  secondary,  757 
of  stomach,  277 
age  in  etiology,  278 
anemia  in  etiology,  279 

treatment,  303 
blood  in,  286 
bowels  in,  care,  307 
cancer  and,  differentiation,  348 

engrafted  on,  347 
changes  in  shape  of  stomach,  326 
chlorosis  in  etiology,  279 
chronic  gastritis  and,  differentiation 

253 
cirrhosis  of  liver  and,  differentiation, 

294. 

collapse  in,  treatment,  298 

complications,  286 

conditions  simulating,  290 

course,  295 

diagnosis,  288,  291,  293 
Bonninger's  method,  289 
a:-ray,  289 

diet  in,  193,  302 

Dieulafoy's,  314 

duodenal  feeding  in,  301 

ulcer  and,  differentiation,  294,  750 

Einhorn's  treatment,  301 

etiology,  277,  278 

Ewald's  treatment,  301 

excision,  312 

extent,  282 

frequency,  278 

gastralgia  and,  differentiation,  477 

gastric  contents  in,  285 

gastrojejunal  ulcer  following,   treat- 
ment, 312 

gastrosuccorhea    continua     chronica 
and,  differentiation,  393 

gelatin  treatment,  306 

geographic  distribution,  277 

hemorrhage  in,  284 
serum  treatment,  297 
treatment,  296,  306 
operative,  309 

Hort's  theory  of,  279 

hyperchlorhydria  and,  281,  283,  286 

differentiation,  376 

hypersecretion  in,  treatment,  309 

in  acute  infectious  diseases,  759 

in  constitutional  diseases,  759 


Ulcer  of  stomach,  in  etiology  of  cancer,  322 
jejunal  ulcer  after,  treatment,  312 
Kemp's  diet  table,  305 

treatment,  298 
lavage  in,  297 
Lenhartz's  treatment,  301 
Leube-Ziemssen  rest-cure  in,  300 
location,  282,  294 
microscopic  anatomy,  281 
morbid  anatomy,  281 
motor  function  in,  285 
nervous   dyspepsia    and,   differentia- 
tion, 497 
number,  282 

occult  hemorrhage  in,  284 
occupation  in  etiology,  278 
pain  in,  284,  285,  289 

from  adhesions  in,  treatment,  309 
treatment,  307 
perforation  in,  287 
treatment,  309 

simple  duodenal  ulcer  and,  differen- 
tiation, 744 
physical  signs  in,  288 

with  little  air  present,  288 
with  much  air  present,  288 
postmortem  distribution,  277 
precancerous  stage,  operation  in,  352- 
prognosis,  295 
progress,  283 

pyloric    obstruction,    surgical    treat- 
ment, 312 
Rontgen  ray  findings  in,  114-118 
Senator's  treatment,  304 
sex  in  etiology,  278 
shallow,  bismuth  or  barium  patch  on, 

116 
Sippy's  treatment,  304 
snail-form  pylorus  in,  290 
spider    gall-bladder    adhesions    and, 

differentiation,  294 
stenosis  with  dilatation  in,  treatment, 

308 
surgical  treatment,  309 
symptoms,  283 
syphilitic,  509 
thirst  in,  treatment,  297 
traumatism  in  etiology,  278 
treatment,  296 
tuberculous   diaphragmatic    pleurisy 

and,  differentiation,  294 
urine  in,  286 

vomiting  in,  treatment,  309 
Weinland's  theory  of,  279 
a;-rays  in,  288 
in  diagnosis,  289 
in  treatment,  309 
peptic,  277.     See  also  Ulcer  of  stomach. 
perforating  gastric,  277.     See  also  Ulcer 

of  stomach. 
stercoral,  of  intestines,  758 
syphilitic,  of  intestines,  759 
thrombotic,  of  intestines,  755 
toxic,  of  intestines,  759 
Ulcerative  colitis,  758 
Ulceration  in  amebic  dysentery,  672 
of  stomach,  superficial,  314 


INDEX 


1 09s 


Ulcus  carcinomatosum,  734 

duodeni  pepticum,  725 

ventriculi,  277.     See  also  Ulcer  of  slow - 
ach. 
Umbilical  dyspepsia,  899 
Umbilicus,  protrusion  of,  diagnostic  value, 

Uncinaria  ameiicana,  941 
Uncinariasis,  940 
incidence,  940 
parasite  of,  941 
Uncinarial  dermatitis,  943 
anemia  in,  945 
autogenous  vaccine  in,  948 
diagnosis,  946 
immunity,  943 
morbid  anatomy,  944 
prognosis,  946 
prophylaxis,  946 
symptoms,  944 
thymol  in,  947 
treatment,  946 
Urine  in  pancreatic  diseases,  987 
Urobiiinuria  in  pancreatic  disease,  987 
Ureter,  Head's  zones  for,  832 
Urine  in  acute  enteritis,  647 
in  cancer  of  stomach,  332 
in  chronic  gastritis,  251 
in  gastric  ulcer,  286 
in  hj'perchlorhydria,  373 
in  simple  acute  gastritis,  238 
reaction,  in  Bacillus  coli  infections,  596, 
607 
Urobilin  in  feces,  536 
Urticaria,  stomach  functions  in,  507 
Uterus,  Head's  zones  for,  833 
Uvula,  inspection  of,  50 

Vaccination,  antityphoid,  707 
Vaccines,  autogenous  in  typhoid  fever,  718 
in  uncinariasis,  948 
therapy  in  typhoid  fever,  713 
Vacuum  bottle  for  proctoclysis,  563 
Vaginal  examination,  digital,  69 
in  appendicitis,  815 
in  rectal  diseases,  524 
Vagotonia,  892 
age  and,  892 
etiology,  893 
relation  of  intestinal  intoxications  to, 

894 
stigmata  of,  895 
symptoms,  894 
treatment,  896 
Valvula  Bauhini,  24 
Valvulae  conniventes  of  Kerkring,  25 
Van  Deen's  test  for  occult  blood,  Weber's 

modification,  160 
Van  Orden  corset,  463 
Van  Slyke's  modification  of  Abderhalden's 

test  in  gastric  cancer,  341 
Van  Valzah-Hayes  belt  in  gastroptosis, 

463 
Vater's  ampulla,  958 

variations,  960 
Vedee  vibrator,  222 
Veins  of  rectum,  31 


Veins  of  small  intestine,  24 

of  stomach,  21 
Venous  hemorrhoids,  783 
Vermes,  924 

Vermiform  appendix,  29.      See    also    Ap- 
pendix, vermiform. 
Vesicocolic  fistula,  diverticulitis  and,  difif- 

erentiation,  855 
Vibrator,  Vedee,  222 

Vibratory  massage  in  chronic  atony  of 
stomach,  400 
in  constipation,  619 
of  stomach,  221 
Villi  of  small  intestines,  26 
Visceral  arteriosclerosis,  588 
crises  in  erythema  group,  896 
diagnosis,  898 
etiology,  897 
symptoms,  896 
treatment,  898 
Visceroptosis,  442.     See  also  Gastroptosis. 
Volatile  acids  in  gastric  contents,  150 
Voluntary  muscles  in  t)T)hoid  fever,  703 
Volvulus,  865 
age  and,  866 
anatomy,  866 
constipation  in,  866 
course,  867 

diagnosis,  differential,  875 
etiology,  865 
frequency,  866 
mechanics,  865 
meteorism  in,  866 
of  sigmoid  flexure,  865 
of  small  intestine,  865 
of  stomach,  441 
diagnosis,  differential,  442 
etiology,  442 
symptoms,  442 
treatment,  442 
pain  in,  866 
sex  and,  866 
symptoms,  866 
Vomit,  bile  in,  157 
blood  in,  157 
examination  of,  156 
food  in,  156 
mucus  in,  157 
parasites  in,  157 
pus  in,  157 

black,  in  appendicitis,  815 
Vomiting,  cyclic,  in  children,  492 
diagnosis,  493 
etiology,  492 
prognosis,  493 
symptoms,  492 
treatment,  493 
delayed  in  acute  atony  of  stomach,  398 
idiopathic  nervous,  494 
in  acute  ecstasy  of  stomach,  409 

intestinal  obstruction,  873 
in  chronic  gastritis,  treatment,  259 

pancreatitis,  1023 
in  gastric  cancer,  329 
treatment,  362 
ulcer,  treatment,  309 
in  pancreatic  diseases,  996 


1096 


INDEX 


Vomiting  in  simple  acute  gastritis,  treat- 
ment, 239 
in  stenotic  ectasy  of  stomach,  treatment, 

432 
juvenile,  494 
nervous,  490 

characteristics,  491 
treatment,  491 
periodic,  491 

in  children,  492 
recurrent,  in  children,  492 
reflex,  494 
Vomito  negro  appendiculaire,  815 
Vomitus  in  gastric  cancer,  335 

in  gastrosuccorrhea  continua  periodica, 

388 
nervosa,  490 
Von  Noorden's  diet  in  obesity,  916 
diet-lists,  183-185 

Water  as  food,  189 
infiltration  treatment  of  hemorrhoids, 

Gant's  793 
inflation  of  colon  with,  531 
of  stomach,  96 
Water-trap  stomach,  37,  456,  457 
Weber's  modification  of  Van  Deen's  test 

for  occult  blood,  160 
Weinland's  theory  of  gastric  ulcer,  279 
Whip-worm,  949 
Whistle,  stomach,  Kemp's,  97 
Whitehead's  operation  for  hemorrhoids, 
793 


Widal's  reaction  in  typhoid  fever,  706 

Winterberg  method  of  determining  num- 
ber of  bacteria  in  feces,  548 

Wirsung's  duct,  958 

Wolff's  artificial  Carlsbad  mixture,  258, 
381 

Wolff- Junghans    test    in    gastric   cancer, 

341 
Wolfler's    signs    in    hour-glass   stomach, 

438 
Worm,  fluke,  930 

hook-,  940 

maggot-,  938 

pin-,  938 

round,  935 

seat,  938  ^ 

spool,  935 

thread-,  938 

whip-,  949 
Wound  infection  with  colon  bacillus,  601 
Wynhausen's  method  of  determining  dia- 
static  ferments  in  feces,  985 

X-RAYS.    See  Rontgen  rays. 

Yeast  in  gastric  contents,  166 

Ziemssen-Leube  rest-cure  in  gastric  ulcer, 

300 
Zinc  salts,  poisoning  with,  antidotes  for, 

245 
Zones,  Head's.     See  Head's  zones. 
Zymogen  rennet,  153 


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It  is  more  than  ever  the  standard. 

American  Journal  of  the  Medical  Sciences 

"  This  edition  has  been  revised,  new  illustrations  added,  and  some  new  matter,  and  really 
is  two  books.  .  .  .  The  descriptions  of  disease  are  clear,  directions  as  to  treatment  definite, 
and  disputed  matters  and  theories  are  omitted.     Altogether  it  is  a  most  useful  text-book." 


Kaplan's  Serology  of  Nervous  and 
Mental  Diseases 

Serology  of  Nervous  and  Mental  Diseases.  By  D,  M.  Kaplan, 
M.  D.,  Director  of  Clinical  and  Research  Laboratories,  Neurological 
Institute,  New  York  City.  Octavo  of  346  pages,  illustrated.  Cloth, 
;^3.50  net. 


This  is  an  entirely  new  work,  giving  you  the  indications,  contra-indications, 
preparation  of  patients,  technic,  after-phenomena,  after-care,  and  disposal  of  the 
fluids  obtained  by  lumbar  puncture.  You  get  a  full  discussion  of  the  serology  of 
all  nervous  and  mental  diseases  of  non-luetic  etiology  (including  disorders  of 
internal  secretion),  and  of  every  type  of  luetic  nervous  and  mental  disease,  giv- 
ing the  Wassermann  reaction  in  detail,  the  use  of  salvarsan  and  neosalvarsan,  etc. 


MENTAL   DISEASES  AND   HYGIENE 


Herrick's  Neurology 

Introduction  to  Neurology.     By  C.  Judson  Herrick,  Ph.  D.,  Pro- 
fessor of  Neurology  in  the  University  of  Chicago.      1 2mo  of  360  pages, 

illustrated.     Cloth,  1^1.75  net. 

RECENTLY  ISSUED 

Professor  Herrick' s  new  work  will  aid  the  student  to  organize  his  knowledge 
and  appreciate  the  significance  of  the  nervous  system  as  a  mechanism  right  at 
the  beginning  of  his  study.  It  is  sufficiently  elementary  to  be  used  by  students 
of  elementary  psychology  in  colleges  and  normal  schools,  by  students  of  general 
zoology  and  comparative  anatomy  in  college  classes,  and  by  medical  students  as 
a  guide  and  key  to  the  interpretation  of  the  larger  works  on  neurology. 


Brill's  Psychanalysis  second  Edition 

Psychanalysis  :  Its  Theories  and  Practical  Application.  By  A.  A. 
Brill,  Ph.  B.,  M.  D.,  Clinical  Assistant  in  Neurology  at  Columbia 
University  Medical  School.     Octavo  of  392  pages.       Cloth,  $3.25  net. 

To  the  general  practitioner,  who  first  sees  these  "borderline"  cases  (the 
neuroses  and  the  psychoses),  as  well  as  to  those  specially  interested  in  neurologic 
work,  Dr.  Brill's  work  will  prove  most  valuable.  Dr.  Brill  has  had  wide  clinical 
experience,  both  in  America  and  in  Europe.  The  results  of  this  experience  you 
get  in  this  book.  Here  you  get  the  practical  application  of  all  Freud's  theories — 
and  from  the  pen  of  a  man  thoroughly  competent  to  write. 

Hunt's  Diagnostic  Symptoms  of  Nervous  Diseases 

Diagnostic  Symptoms  of  Nervous  Diseases.  By  Edward  L. 
Hunt,  M.  D.,  formerly  Instructor  in  Neurology  and  Assistant  Chief  of 
Clinic,  College  of  Physicians  and  Surgeons,  New  York.  i2mo  of  229 
pages,  illustrated.     Cloth,  $1.50  net. 

Stiles  on  the  Nervous  System 

The  Nervous  System  and  its  Conservation.  By  Percy  G.  Stiles, 
Instructor  in  Physiology  at  Harvard  University.  i2mo  of  230  pages, 
illustrated.     Cloth,  $1.25  net. 


SAUNDERS  BOOKS    ON 


American  Illustrated  Dictionary 

New  (8th)  Edition— 1500  New  Words 

The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches;  with  over  100  new  and  elaborate  tables  and  many  hand- 
some illustrations.  By  W,  A.  Newman  Borland,  M.  D.  Large 
octavo,  1 1 37  pages,  bound  in  full  flexible  leather,  $4. 50  net ;  with  thumb 
index,  ;^5.oo  net. 

The  American  Illustrated  Medical  Dictionary  defines  hundreds  of  terms  not 
defined  in  any  other  dictionary — bar  none.  It  gives  the  capitalization  and  pro- 
nunciation of  all  words.  It  makes  a  feature  of  the  derivation  or  etymology  of  the 
words.  Every  word  has  a  separate  paragraph,  thus  making  it  easy  to  find  a 
word  quickly.  The  tables  of  arteries,  muscles,  nerves,  veins,  etc.,  are  of  the 
greatest  help  in  assembling  anatomic  facts.  Every  word  is  given  its  definition — a 
definition  that  defines  in  the  fewest  possible  words. 

Howard  A.  Kelly,  M.  D.,  Johns  Hopkins  University,  Baltimore. 

"  The  American  Illustrated  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such 
convenient  size.    No  errors  have  been  found  in  my  use  of  it." 

Owen's  Treatment  of  Kmerg'encies 

The  Treatment  of  Emergencies.  By  Hubley  R.  Owen,  M.  D., 
Surgeon  to  the  Philadelphia  General  Hospital.  i2mo  of  350  pages, 
with  249  illustrations.  Just  Issued. 

Dr.  Owen's  book  is  a  complete  treatment  of  emergencies.  It  gives  you  not 
only  the  actual  technic  of  the  procedures,  but,  what  is  equally  important,  the  un- 
derlying principles  of  the  treatments,  and  the  reason  why  a  particular  method  is 
advised.  .  You  get  treatments  of  fractures,  of  contusions,  of  wounds.  Particularly 
strong  is  the  chapter  on  gun-shot  wounds,  which  gives  the  new  treatments  that  the 
great  European  War  has  developed.  You  get  the  principles  of  hemorrhage,  to- 
gether with  its  constitutional  and  local  treatments.  You  get  chapters  on  sprains, 
strains,  dislocations,  burns,  sunburn,  chilblain,  asphyxiation,  convulsions,  hysteria, 
apoplexy,  exhaustion,  opium  poisoning,  uremia,  electric  shock,  bandages,  and 
a  complete  discussion  of  artificial  respiration,  including  mechanical  devices. 


DISEASES   OF   CHILDREN. 


Kerley*s  Pediatrics 


Practice  of  Pediatrics.  By  Charles  Gilmore  Kerley,  M.  D., 
Professor  of  Diseases  of  Children,  New  York  Polyclinic  Medical  School 
and  Hospital.  Octavo  of  878  pages,  illustrated.  Cloth,  ^6.00  net; 
Half  Morocco,  $7.^0  net. 

FOURTH  LARGE  PRINTING 

This  work  is  not  a  cut-and-dried  treatise — but  th.G  practice  of  pediatrics,  giving 
fullest  attention  to  diagnosis  and  treatment.  The  chapters  on  the  newborn  and  its 
diseases,  the  feeding  and  growth  of  the  baby,  the  care  of  the  mother's  breasts, 
artificial  feeding,  milk  modification  and  sterilization,  diet  for  older  children — from 
a  monograph  of  125  pages.  Then  are  discussed  in  detail  every  disease  of  child- 
hood, telling  just  what  measures  should  be  instituted,  what  drugs  given,  60  valu- 
able prescriptions  being  included.  The  chapter  on  vaccina  therapy  is  right  down  to 
the  minute,  including  every  new  method  of  proved  value — with  the  exact  technic. 
There  is  an  excellent  chapter  on  Gymtiastic  Therapeutics.  Another  feature  con- 
sists of  the  i6j  illustrative  cases — case  teaching  of  the  most  practical  sort. 

Dr.  A.  D.  Blackader,  McGill  University,  Montreal 

"  Dr.  Kerley  is  a  pediatrician  of  large  experience  who  thinks  for  himself  and  is  never  con- 
tent to  accept,  without  testing,  the  experiences  or  statements  of  previous  writers.  His  book  has 
a  very  definite  value." 


Bandler's  The  Expectant  Mother 

Just  Out 

This  is  decidedly  a  book  for  the  woman  preparing  for  childbirth.  It  has 
chapters  on  menstruation,  nourishment  of  mother  during  pregnancy,  nausea, 
care  of  breasts,  examination  of  urine,  preparations  for  labor,  care  of  mother  and 
child  after  delivery,  twilight  sleep,  and  dozens  of  other  matters  of  great  interest 
to  the  expectant  mother. 

i2mo  of  213  pages,  illustrated.  By  S.  Wyilis  Bandler,  M.  D.,  Professor  of  Diseases  of  Women,  New 
York  Post-Graduate  Medical  School  and  Hospital.  Cloth,  $1.25  net. 

Winslow's  Prevention  of  Disease 

Just  Ready 

This  book  is  a  practical  guide  for  the  layman,  giving  him  briefly  the  means 
to  avoid  the  various  diseases  described.  The  chapters  on  diet,  exercise,  tea, 
coffee,  and  alcohol  are  of  special  interest,  as  is  that  on  the  prevention  of  cancer. 
There  are  chapters  on  the  prevention  of  malaria,  colds,  constipation,  obesity, 
nervous  disorders,  tuberculosis,  etc.  The  work  is  a  record  of  twenty-five 
years'  active  practice. 

i2mo  of  348  pages,  illustrated.  By  Kenelm  Winslow,  M.  D.,  formerly  Assistant  Professor  of  Com- 
parative Therapeutics,  Harvard  University.  Cloth,  $i.7S  net. 

Kerr's  Diagnostics  of  Children's  Diseases 

Dr.  Kerr's  work  is  written  absolutely  for  the  general  practitioner — to  aid  him 
in  diagnosing  disease  in  his  child  patients.  He  approaches  his  subject  as  the 
child  is  approached  in  the  sick-room.  It  is  strictly  a  clinical  work — a  first  aid 
in  the  diagnosis  of  disease  in  children. 

Octavo  of  S42  pages,  illustrated.  By  Le  Grand  Kerr,  M.  D.,  Professor  of  Diseases  of  Children  in  the 
Brooklyn  Postgraduate  Medical  School.  Brooklyn.  Cloth,  $5.00  net;    Half  Morocco,  $6.so  net. 


SAUNDERS'  BOOKS    ON 


Hill  and  Gerstley's  Infant  Feeding  Ready  soon 

Clinical  Lectures  in  Infant  Feeding.  By  Lewis  Webb  Hill, 
M.  D.,  Alumni  Assistant  in  Pediatrics,  Harvard  Medical  School,  and 
Jesse  R.  Gerstley,  M.  D.,  Clinical  Assistant  in  Pediatrics,  North- 
western University  Medical  School.     i2mo  of  300  pages,  illustrated. 

In  these  clinics  you  are  given  the  full  details  of  the  Boston  method  of  infant 
feeding  as  developed  by  Dr.  Rotch,  and  of  the  Chicago  method.  You  are  given  the 
theory,  use  in  both  normal  and  abnormal  cases,  exact  quantities  and  percentages, 
and  concrete  clinical  examples.  The  book  is  equivalent  to  a  postgraduate  course 
in  infant  feeding.     It  brings  these  two  systems  right  to  your  door. 

Abt's  Preparation  of  Infants'  Foods         Ready  soon 

The  Preparation  of  Infants'  Foods.  By  Isaac  A.  Abt,  M.  D., 
Professor  of  Diseases  of  Children,  Northwestern  University  Medical 
School.     i2mo  of  100  pages. 

This  is  a  practical  guide  for  infant  feeding,  giving  to  young  mothers,  nurses,  and 
caretakers  minute  directions  on  the  preparation  of  food  for  infants  and  young 
children.  You  get  weights  and  measures;  the  mineral  constituents  and  caloric 
values  of  foods.  You  get  such  practical  material  as  diet-lists  for  constipation  in 
older  children,  an  outline  of  a  plan  for  feeding  babies,  care  of  nipples  and  bottles, 
etc.,  and  a  great  host  of  recipes  for  beverages  of  all  kinds,  milk  preparations,  soups 
and  broths,  puddings  and  cereal  preparations,  custards,  eggs,  vegetables,  fruits, 
meats,  sea  foods,  and  breads. 

Aikens'  Home  Nurse's  Hand-Book  ^ew  (zd/Edmon 

Home  Nurse's  Hand-Book.  By  Charlotte  A.  Aikens.  i2mo  of 
303  pages,  illustrated.  Cloth,  $1.50  net. 

The  point  about  this  work  is  this :  It  tells  you  and  shows  you  just  how  to  do  those 
little  but  important  things  often  omitted  from  other  nursing  books.  "Home  Treat- 
ments" and  "Points  to  be  Remembered" — terse,  crisp  reminders — stand  out  as  par- 
ticularly practical.     Just  the  book  for  those  who  have  the  home-care  of  the  sick. 

Galbraith's  Personal  Hygiene  for  Women         ^^^jgn 

Personal  Hygiene  and  Physical  Training  for  Women.  By 
Anna  M.  Galbraith,  M.  D.,  Fellow  New  York  Academy  of  Medicine. 
1 2mo  of  393  pages,  with  original  illustrations.  Cloth,  $2.25  net. 

"  It  contains  just  the  sort  of  information  which  is  very  greatly  needed  by  the  weaker 
sex.     Its  illustrations  are  excellent." — Dietetic  and  Hygienic  Gazette. 

Galbraith's  Four  Epochs  of  Woman's  Life  ""^iMtl 

The  Four  Epochs  of  Woman's  Life.  By  Anna  M.  Galbraith, 
M.D.  With  an  Introductory  Note  by  John  H.  Musser,  M.  D.,  Uni- 
versity of  Pennsylvania.     1 2mo  of  296  pages.  Cloth,  $1.50  net. 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public ; 
but  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is,  in  the  main,  wise  and  whole- 
some."— Birmingham  Medical  Review. 


CHILDREN  AND   HYGIENE 


Griffith's  Care  of  the  Baby 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Professor 
of  Pediatrics  in  the  University  of  Pennsylvania.  i2mo  of  455  pages, 
illustrated.     Cloth,  $1.50  net. 

THE  NEW  (6th)  EDITION 

The  author  has  endeavored  to  furnish  a  reliable  guide  for  mothers.  He  has 
made  his  statements  plain  and  easily  understood,  so  that  the  volume  will  be  of 
service  to  mothers  and  nurses. 

New  York  Medic&l  Journal 

"We  are  confident  if  this  Itttle  work  could  find  its  nhf  into  the  hands  of  every  trained 
nurse  and  of  every  mother,  infant  mortality  would  be  lesseAed  by  at  least  fifty  per  cent." 


Grulee's  Infant  Feeding 

Infant  Feeding.  By  Clifford  G.  Grulee,  M.  D.,  Assistant  Pro- 
fessor of  Pediatrics  at  Rush  Medical  College.  Octavo  of  3 16  pages,  illus- 
trated, including  8  in  colors.     Cloth,  ;^3.oo  net. 

NEW  (2d)  EDITION 

Dr.  Grulee  tells  you  how  to  feed  the  infant.  He  tells  you — and  shows  by  clear 
illustrations — the  icchnic  of  giving  the  child  the  breast.  Then  artificial  feeding  is 
thoughtfully  presented,  including  a  number  of  simple  formulas.  The  colored  illus- 
trations showing  the  actual  shapes  and  appearances  of  stools  are  extremely 
valuable. 


Ruhrah's   Diseases   of   Children 

A  Manual  of   Diseases  of   Children.     By  John  Ruhrah,  M.  D., 

Professor  of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 

Baltimore.     i2mo  of  552  pages,    fully    illustrated.     Flexible   leather, 
$2.75  net. 

FOURTH   EDITION 

In  revising  this  work  for  the  fourth  edition  Dr.  Ruhrah  has  carefully  in- 
corporated all  the  latest  knowledge  on  the  subject.  All  the  important  facts  are 
given  concisely  and  explicitly,  the  therapeutics  of  infancy  and  childhood  being 
outlined  very  carefully  and  clearly.  There  are  also  directions  for  dosage  and 
prescribing,  and  many  useful  prescriptions  are  included. 

American  Journal  of  the  Medical  Sciences 

"  Treatment  has  been  satisfactorily  covered,  being  quite  in  accord  with  the  best  teaching, 
yet  withal  broadly  general  and  free  from  stock  prescriptions." 


SAUNDERS'    BOOKS    ON 


Keefer*s  Military  Hygiene 

Military  Hygiene  and  Sanitation.  By  Lieut.-Col.  Frank  R. 
Keeper,  Professor  of  Military  Hygiene,  United  States  Military  Academy, 
West  Point.     i2mo  of  305  pages,  illustrated.     Cloth,  $1.50  net. 

ILLUSTRATED 

This  is  a  concise,  though  complete  text-book  on  this  subject,  containing 
chapters  on  the  care  of  troops,  recruits  and  recruiting,  personal  hygiene,  physical 
training,  preventable  diseases,  clothing,  equipment,  water-supply,  foods  and  their 
preparation,  hygiene  and  sanitation  of  posts  and  barracks,  the  troopship,  hygiene 
and  sanitation  of  marches,  camps,  and  battlefields,  disposal  of  wastes,  tropical  and 
arctic  service,  venereal  diseases,  alcohol  and  other  narcotics,  and  a  glossary. 

Bergey*s  Hygiene 

The  Principles  of  Hygiene;  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  By  D.  H.  Bergey,  A.  M.,  M.  D., 
Assistant  Professor  of  Bacteriology  in  the  University  of  Pennsylvania. 
Octavo  volume  of  531  pages,  illustrated.  Cloth,  $3.00  net. 

FIFTH   EDITION 

This  book  is  intended  to  meet  the  needs  of  students  of  medicine  in  the 
acquirement  of  a  knowledge  of  those  principles  upon  which  modern  hygienic 
practises  are  based,  and  to  aid  physicians  and  health  officers  in  familiarizing 
themselves  with  the  advances  made  in  hygiene  and  sanitation  in  recent  years. 
This  fifth  edition  has  been  very  carefully  revised,  and  much  new  matter 
added,  so  as  to  include  the  most  recent  advancements. 

Buffalo  .Medical  Journal 

•'  It  wall  be  found  of  value  to  the  practitioner  of  medicine  and  the  practical  sanitarian  ;  and 
students  of  architecture,  who  need  to  consider  problems  of  heating,  lighting,  ventilation,  water 
supply,  and  sewage  disposal,  may  consult  it  with  profit." 

Pyle's  Personal  Hygiene  The  New  (6th)  Edition 

A  Manual  of  Personal  Hygiene  :  Proper  Living  upon  a  Physiologic 
Basis.  By  Eminent  Specialists.  Edited  by  Walter  L.  Pyle,  A.  M., 
M.  D.,  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia.  Octavo 
volume  of  541  pages,  fully  illustrated.  Cloth,  $1.50  net. 

The  book  has  been  thoroughly  revised  for  this  new  edition,  and  a  new  chapter  on 
Food  Adulteration  by  DR.  HARVEY  W.  WiLEY  added.  There  are  important  chapters 
on  Domestic  Hygiene  and  Home  Gymnastics,  Hydrotherapy,  Mechanotherapy,  and 
First  Aid  Measures. 

"  The  work  has  been  excellently  done,  there  is  no  undue  repetition,  and  the  writers 
have  succeeded  unusually  well  in  presenting  facts  of  practical  significance  based  on  sound 
knowledge." — Boston  Medical  and  Surgical  Journal. 


LEGAL   MEDICINE 


Bohm  and  Painter's  Massage 

Massage.  By  Max  Bohm,  M.  D.,  of  Berlin,  Germany.  Edited,  with  an 
Introduction,  by  Charles  F.  Painter,  M,  D.,  Professor  of  Orthopedic  Sur- 
gery at  Tufts  College  Medical  School,  Boston.  Octavo  of  91  pages,  with  97 
/;ra^AVa/ illustrations.  Cloth,  $1.75  net. 

Draper's  Legal  Medicine 

A  Text-Book  of  Legal  Medicine.  By  Frank  Winthrop  Draper,  A.  M., 
M.  D.,  Late  Professor  of  Legal  Medicine  in  Harvard  University,  Boston. 
Octavo  of  573  pages,  illustrated.     Cloth,  $4.00  net ;  Half  Morocco,  $5.50  net 

Golebiewski  and  Bailey's  Accident  Diseases 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.     By  Dr.  Ed. 

Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce  Bailey,  M.  D., 
Consulting  Neurologist  to  St.  Luke's  Hospital,  New  York.  With  71  colored 
illustrations  on  40  plates,  143  text  illustrations,  and  549  pages  of  text.  Cloth, 
$4.00  net.     In  Saunders'  Hand-Atlas  Series. 

Hofmann  and   Peterson's   Legal   Medicine      HandXi^t 

Atlas  of  I^egal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna. 
Edited  by  Frederick  Peterson,  M.  D.,  Professor  of  Psychiatry  in  the 
College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures 
on  56  plates  and  193  half-tone  illustrations.     Cloth,  $3.50  net. 

Jakob  and  Fisher's  Nervous  System  ^'"AtiSli 

Atlas  and   Epitome  of  the  Nervous  System  and  its  Diseases.      By 

Professor  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with  additions,  by  Ed- 
ward D.  Fisher,  M.  D.,  University  and  Bellevue  Hospital  Medical  College. 
With  83  plates  and  copious  text.     Cloth,  $3. 50  net. 

Spear's  Nervous  Diseases  J«»t  out 

A  Manual  of  Nervous  Diseases.  By  Irving  J.  Spear,  M.  D,.  Professor 
of  Neurology  at  the  University  of  Maryland,  Baltimore.  1 2mo  of  660  pages, 
illustrated.  Cloth,  $2.75  net. 

This  is  a  comprehensive  digest,  supplying  the  means  to  a  clear  understanding  of 
neurology,  and  robbing  that  subject  of  much  of  its  difficulty.  You  are  given,  first, 
a  brief  description  of  the  practical  anatomy  and  physiology,  with  those  facts  and 
theories  that  bear  on  the  mechanism  of  organic  nervous  diseases.  Then  pathology 
is  given,  the  simpler  diseases  being  considered  first,  gradually  preparing  the  reader 
to  grasp  the  more  difficult  ones.  The  descriptions  are  clear  and  brief,  diferenlial 
diagnoses  and  treatments  being  brought  out  very  definitely.  Only  the  most  recent 
accepted  facts  have  been  considered.  For  the  treatments  recommended,  no  special 
apparatus  is  required  beyond  a  galvanic  and  faradic  battery;  they  demand  no 
special  training,  and  they  are  easily  remembered. 


SAUNDERS'   BOOKS  ON  CHILDREN. 


American  Pocket  Dictionary  New  (9th)  Edition 

American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  New- 
man Borland,  M.  D.,  Editor  "American  Illustrated  Medical  Dic- 
tionary." Containing  the  pronunciation  and  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences,  with  75  extensive  tables. 
With  693  pages.  Flexible  leather,  with  gold  edges,  $1.25  net;  with 
patent  thumb  index,  $1.50  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  Dean 
of  the  Jefferson  Medical  College,  Philadelphia. 

Morrow's  Immediate  Care  of  Injured  second  Edition 

Immediate  Care  of  the  Injured.  By  Albert  S.  Morrow,  M.  D., 
Adjunct  Professor  of  Surgery  at  the  New  York  Polyclinic.  Octavo  of  360 
pages,  with  242  illustrations.      Cloth,  $2.50  net. 

Dr.  Morrow's  book  on  emergency  procedures  is  written  in  a  definite  and  decisive  style, 
the  reader  being  told  just  what  to  do  in  every  emergency.  It  is  a  practical  book  for  every 
day  use,  and  the  large  number  of  excellent  illustrations  can  not  but  make  the  treatment  to 
be  pursued  in  any  case  clear  and  intelligible.    Physicians  and  nurses  will  find  it  indispensible. 

Powell's    Diseases    of   Children  Third  Edition.  Revised 

Essentials  of  the  Diseases  of  Children.  By  William  M.  Powell, 
M.  D.  Revised  by  Alfred  Hand,  Jr.,  A.  B.,  M.  D.,  Dispensary 
Physician  and  Pathologist  to  the  Children's  Hospital,  Philadelphia. 
i2mo  volume  of  259  pages.  Cloth,  $1.25  net.  In  Saunders* 
Question-  Compend  Series. 

Shaw  on  Nervous  Diseases  and  Insanity        Fifth  Edition 

Essentials  of  Nervous  Diseases  and  Insanity:  Their  Symptoms 
and  Treatment.  A  Manual  for  Students  and  Practitioners,  By  the  late 
John  C.  Shaw,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Mind  and 
Nervous  System,  Long  Island  College  Hospital,  New  York.  i2mo  of 
204  pages,  illustrated.  Cloth,  $1.25  net.  In  Saunders*  Question-Corn' 
pend  Series. 

"  Clearly  and  intelligently  written ;  we  have  noted  few  inaccuracies  and  several  sug' 
gestive  points.  Some  affections  unmentioned  in  many  of  the  large  text-books  are  noted.'' 
— Boston  Medical  and  Surgical  Journal. 

Brady's  Personal  Health  just  out 

Personal  Health:  A  Doctor  Book  for  Discriminating  People.  By 
William  Brady,  M.D.,  Elmira,  N.  Y.  i2mo  of  406  pages.  Cloth,  ;^  1.50  net. 

Hecker,  Trumpp,  and  Abt  on  Children 

Atlas  and  Epitome  of  Diseases  of  Children.  By  Dr.  R.  Hecker 
and  Dr.  J.  Trumpp,  of  Munich.  Edited,  with  additions,  by  Isaac  A. 
Abt,  M.D.,  Assistant  Professor  of  Diseases  of  Children,  Rush  Medical 
College,  Chicago.  With  48  colored  plates,  144  text-cuts,  and  453  pages 
of  text.     Cloth,  $5.00  net. 

The  many  excellent  lithographic  plates  represent  cases  seen  in  the  authors'  clinics,  and 
have  been  selected  with  great  oare,  keeping  constantly  in  mind  the  practical  needs  of  the 
general  practitioner.  These  beautiful  pictures  are  so  true  to  nature  that  their  study  is 
equivalent  to  actual  clinical  observation.  The  editor,  Dr.  Isaac  A.  Abt,  has  added  all  new 
methods  of  treatment. 


Date  Due                    , 

rwvJ^  I 

1979 

rife  2 

t    REC'O 

puiNTCD  IN  U.S.*.            CAT.   NO.   24    161               Im 

WI  100 
K32d 

1917 
Kemp,  Robert  Coleman 

Diseases  of  the  stomach, 
intestines,  and  pancreas 


WI  100 

K32d 

1917 
|Kemp,  Robert  Coleman 

Diseases  of  the  stomach,  intestines, 
and  pancreas 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


